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PROSTATIC HYPERTROPHY 



FROM 



EYERY SDRGICAL STANDPOINT 

BY 

GEORGE M. PHILLIPS, M. D. 

AND 

FORTY DISTINGUISHED AUTHORITIES 



EDITED AJS"D COMPILED 



S. C. MARTIN, Jr., M. D. 



THE AJOD COMPANY 

MEDICAL PUBLISHERS 

FIDELITY BUILDING 

ST. LOUIS. U. S. A. 






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COPYRIGHT 1903 
BY 

The Ajod Company, 

S'c. T'Ouis, Mo., 
U.S.A. 






— PRESS OF — 

The Ajod Company. 



CONTRIBUTORS, 



John A.Wyeth, M. D. 

Robert T. Morris, M. D. 

John B. Murphy, M. D. 

Roswell Park, M. D. 

Eugene Fuller, M. D. 

Edward Martin, M. D. 

William K. Otis, M. D. 
Alexander H. Ferguson, M. D. Carl Beck, M. D. 

Hilary M. Christian, M. D. 
Charles H. Mayo,'M. D. 

Granville Mac Go wan, M. D. 

N. Pendleton Dandridge, M. D. 

Joseph Rilus Eastman, M. D. 
William N. Wishard, M. D. Ramon Guiteras, M. D. 

George C. MacDonald, M. D. 

Walter G. Spencer, F.R.C.S., M.S., M.B. 
Andrew C. Smith, M. D. 
Jacob Geiger, M. D. 

Nicholas Senn, M. D. 
Albert J. Ochsner, M. D. Edmund Andrews, M. D. 

Augustus C. Bernays, M. D. 
Bransford Lewis, M. D. 

Orville Horwitz, M. D. 

Robert H, Greene, M. D. 
Howard Lilienthal, M. D. Stuart McGuire, M. D. 

Charles Chassaignac, M. D. 
Henry H. Morton, M. D. 

W. Frank Glenn, M. D. 

B. Merrill Ricketts, M. D. 
Dennis J. Hayes, M. D. Ferd. C. Valentine, M. D. 
J. Henry Dowd, M. D. A. E. Halstead, M. D. 

Paola De Vecchi, M. D. 

William Jones, M. D. 

Ernest G. Mark, M. D. 

George M. Phillips, M. D. 



PREFACE. 



It would appear from the number and character of authori- 
ties interested in this matter, that a publication of greatly in- 
creased proportions would be necessary. The aim of the au- 
thor in this instance is merely to bring to the notice of the prac- 
ticing physician the advances made in recent years in this line 
of work, and to enable him with minimum effort to talk intelli- 
gently with his prostatic sufferers. 

It very often becomes necessary for the family physician to 
acquaint his patient with the views of those especially devoted 
to this work, to outline the treatment, and discuss in detail the ad- 
vantages of certain operative procedures, and even carry the pa- 
tient step by step through the proposed operation. It also hap- 
pens that impressions in this way made have been misleading. 
The patient -may be unduly or insufficiently impressed with the 
trials that await him, and as a result the surgeon or the attending 
physician must enter into explanations that are tedious, and not 
always satisfactory. 

The object of this, then, aside from that which has just been 
given, is to enable the physician in charge of such cases to se- 
lect a surgeon and to prepare such patients in advance to re- 
ceive the services of the specialist. 

George M. Phillips, M. D. 
November, 1903. 



INTRODUCTION. 



The subject of hypertrophy of the prostate is 
not new, but, on the contrary, is one that has en- 
gaged the attention of medical men from the earli- 
est record. It is not a condition confined to a given 
locality, nor is it one appearing at particular sea- 
sons, but one that selects for its victims men who 
have passed the meridian of life without regard to 
habit, former health or activity. It is a condition 
not unusually considered a disease, yet, as we will 
soon see, is a condition the complications of which 
very often strips the declining years of man of the 
usefulness and pleasure for which he has so long 
labored, and commits to the grave yearly many who 
were other wise entitled to live. One is often im- 
pressed with the idea that discoveries, inventions, 
improvements and truly great advances travel in 
cycles or waves, and this seems to hold true with 
reference to the above subject. Prostatic manipula- 
tion and consideration within the past few years 
has been very general. From every quarter evidence 
has come of scientific work. Men who for years 



12 INTRODUCTION. 

have been silent upon this subject have become 
awakened. Surgeons in general have consented, 
specialists in this department have forged forward 
and blazed the way, which has been taken up by 
all who are interested in the betterment of man- 
kind. This volume is devoted and, I might say, 
dedicated to this class of workers. The time de- 
voted to the collection and compilation of the 
views and experiences of this talent and the space 
given is our best acknowledgment of appreciation. 
Every one solicited to participate in this matter 
has been asked for an answer to the fourteen ques- 
tions here enumerated: 

Question No. 1. 

To what extent does occupation tend to prostatic 
hypertrophy? Answer with especial reference to 
active indoor, active outdoor and sedentary pur- 
suits. 

Question No. 2. 

Which suffer oftenest, the phlegmatic or nerv- 
ous? The lean or obese? 

Question No. 3. 

In brief, what is the etiology of prostatic hyper- 
trophy? 



introduction. 13 

Question No. 4. 

To what extent has the cystoscope been of ser- 
vice in diagnosis, and what instrument is prefer- 
red? 

Question No. 5. 

To what extent is habit responsible for prostatic 
hypertrophy? Ansiver with especial reference to 
the use of alcohol and constipation. 

Question No. 6. 

What cases do you advise palliation, and of what 
does this consist? 

Question No. 7. 

Have you practiced ligation of vasa deferentia? 
How many cases, and ivith what results? 

Question No. 8. 

Have you castrated for prostatic hypertrophy? 
How often, and with what success? 

Question No. 9. 

Have you made the Bottini, or some modification 
of this operation? How often and with ivhat suc- 
cess? Answer with reference to complications, per- 
manency of relief, etc. 



14 INTRODUCTION. 

Question No. 10. 

How often have you practiced supra-pubic drain- 
age, and what is your estimate of results f 

Question No. 11. 

Row often have you made supra-pubic prosta- 
tectomy, and what have been the results obtained? 

Question No. 12. 

How often have you made a perineal prostatect- 
omy, and with ivhat success? What incision in the 
perineum affords you greatest room? 

Question No. 13. 
Which is the operation of your choice, and why? 

Question No. 14. 

What unexpected complications have arisen dur- 
ing the operation for prostatic hypertrophy , and 
what during the post-operative conduct of the case? 

A. 

Give brief resume of your prostatic work. 

And their several responses collected are here 
submitted. 



ANATOMY OP PROSTATE. 15 

Before entering upon the analysis of these an- 
swers, however, it might be well to briefly consider 
in a general way some features of the prostate. 
The author in so doing will be pardoned for omis- 
sions, and any theory or view that may be at vari- 
ance with those of others ; as far as possible he will 
offer such as he personally believes, and which, for 
the most, are those that are generally accepted. He 
will be pardoned also for reference to the anatomy 
and physiology of this organ, for it might appear 
that the intelligence of the reader would in this 
way be insulted. That this small volume is to be 
broadly circulated, and will fall into the hands of 
many less versed upon this subject than those con- 
tributing, it has been considered well to have it con- 
venient. 

ANATOMY OF PROSTATE. 



The prostate is a musculo-grandular body, quite 
three-fourths being muscular of the unstriped va- 
riety and one-fourth glandular tissue (vacuum). 
In size and shape it is likened to a horse chestnut. 
More scientific, it is in shape a truncated cone 
measuring in length 30 to 45 mm. ; width of base 
35 to 50 mm. ; thickness 15 to 25 mm., and weigh- 
ing about 15 to 20 grammes. Its position is 5 to 




Fig. 2. 



Figure 1. 

No. 1. Ureters. 

No. 2. Fundus of Bladder. 

No. 3. Base of Bladder. 

No. 4. Vas Deferens. 

No. 5. Seminal Vesicles. 

No. 6. Prostate Gland. 

No. 7. Cowper's Glands. 

No. 8. Bulbous Portion of Spongy 

Urethra. 

No. 9. Corpora Cavernosa. 

No. 10. Fraenum Praeputii. 

No. 11. Glans-Penis. 

No. A. Prostatic Urethra. 

No. B. Membranous Urethra. 

No. C. Spongy Urethra. 

Figure 2. 

No. 1. Ureters. 

No. 2. Fundus of Bladder. 

No. 3. Ureteral Openings. 

No. 4. Trigonum Vesicae. 

No. 5. Veru Montanum. 

No. 6. Sinus Pocularis. 

No. 7. Prostate Gland. 

No. 8. Prostatic Sinuses. 

No. 9. Crus of Corpus Cavernosum. 

No. 10. Ducts of Cowper's Glands. 

No. 11. Fibrous Fascia. 

No. 12. Corpus Cavernosum. 

No. 13. Integument. 

No. 14. Urethral Follicles. 

No. 15. Fossa Navicularis. 

No. 16. Lacuna Magna. 



18 ANATOMY OF PROSTATE. 

15 mm. below the symphysis pubis, 25 to 40 mm. 
from the anus; it surrounds the posterior urethra 
and bladder neck. 

It is held in place by the pubo-prostatic liga- 
ments and anterior fibers of the levator ani muscles. 
Between the prostate and rectum is a quantity of 
loose fascia and the prostatic plexus of veins. Nor- 
mally the prostate is in the two lateral lobes, separ- 
ated by a depression or fissure which is readily de- 
tected with the examining finger; additional lobes, 
bars or irregularities are the result of changes com- 
ing through age, disease or injury. 

The prostate is enveloped in a dense fibrous cap- 
sule, reflections of which are diverted into the sub- 
stance of the organ. 

The vacuum glands found here present columnar 
epithelium. They are surrounded by muscular tis- 
sue and empty into the prostatic urethra through a 
prostatic duct. 

About the office of the prostate there has been 
much conjecture, though today it is generally con- 
ceded to be purely a sexual organ, and that any 
other function it may possess is secondary. Many 
claim that the prostate by encircling the bladder 
neck acts as a sphincter muscle, but later research 
does not bear out such a view. The prostatic ure- 
thra extends the entire length of the organ; it is 



PHYSIOLOGY OF THE PROSTATE. 19 

roomy, and within it is much that is interesting; 
here we find the ducts of the glands that enter into 
its make-up, here the opening of the ejaculatory 
ducts, the verumontanum and sinus pocularis. 

PHYSIOLOGY OF THE PROSTATE. 



Through its muscular endowment the prostate 
controls the ejaculatory ducts, and in this way the 
seminal fluid is taken from the vesicles into the 
prostatic urethra, where it is mixed with the pros- 
tatic secretion. Through its muscular nature this 
fluid is compressed sufficiently to send it with tell- 
ing effect into the vagina and against the cervix to 
develop at the critical moment in the female sexual 
satisfaction. 

Within the mucous membrane of the prostate are 
found a system of nerves, the behavior of which is 
an unsolved problem; disturbances here often give 
rise to that mysterious and puzzling condition rec- 
ognized as sexual neurasthenia, the remedy of 
which is making peace with this part. 

The glandular feature of the prostate performs a 
distinct and important function. The secretion is 
a thin opaque, alkaline material, with strong sper- 
matic odor. The recognized use of which, is a dilu- 



20 PATHOLOGY OF PROSTATIC HYPERTROPHY. 

ent and antiseptic for the spermatic fluid that of- 
fers food and protection to the spermatozoa. Thus 
it will be seen that the prostate is not only a sexual 
organ, but one that is absolutely indispensable, that 
without it the race would end and without it the 
pleasure of sexual contact would be wanting. 

PATHOLOGY OF PROSTATIC HYPERTROPHY. 



There is so little known of the pathogenesis of 
this condition that this part of the subject might 
well be passed, and we are by no means of one ac- 
cord upon what little that is known. That it is a 
chronic non-inflammatory hyperplasia, affecting 
both its glandular and muscular composition, most 
of us are ready to admit. Arterio-sclerosis has 
been advanced and defended by Guyon and Lan- 
nois, and as ably denied and disputed by Casper, 
Motz and others. The analogy between the uterus 
and the prostate and the fibromyoma theory of 
Thompson and Velpeau has faded under the light 
of modern research, for pathologists agree that it is 
adeno-fibroma. 

The chronic congestion theory is faulty and can- 
not be supported by fact. 

The theory of White and Martin has found many 
supporters, and the author for a time was impressed 




Fig. 3. — Hypertrophy of the Prostate. 
1. Prostate. 2. Bas-fond. 



PATHOLOGY OF PROSTATIC HYPERTROPHY. 23 

with it, but confesses today that neither this nor 
any position thus far taken adds greatly to his lim- 
ited knowledge or throws light upon the subject 
generally. 

Examining for prostatic hypertrophy we find 
great variations in size, shape and firmness of this 
body. All parts do not seem to take on this hyper- 
trophy at the same time and in the same way. Ex- 
amining microscopically this body when it is re- 
moved, we verify our original conclusions. Many 
little tumors of unequal size and shape are seen 
when the gland is incised. We find them soft and 
hard. In fact, it is usual to see such an arrange- 
ment, with here and there a trace of normal-looking 
tissue. Very often the removed gland appears even 
more complex, and careful microscopic examina- 
tion shows considerable that is pathologic. But we 
must bear in mind that this part has been subject 
to long and great abuse prior to its removal ; that 
an advancing prostatic hypertrophy begets inflam- 
matory conditions in neighboring parts, which 
often are reflected back to it; that concretions are 
frequent, abscesses and ulcerations follow. We 
know as well the necessity for catheterization, and 
how reckless and septic the conditions usually are 
that mark this operation. 



24 PATHOLOGY OF PROSTATIC HYPERTROPHY. 

I think, in view of all the facts attached to this 
condition, we may be content, for the present at 
least, with the work now doing, and that our lim- 
ited knowledge upon certain features of prostatic 
hypertrophy should only intensify our interest in 
the more practical directions. 

Prostatic hypertrophy is at all times easy of 
diagnosis. The means and instruments for this 
alone are ever at hand. To accurately measure the 
overgrowth or to determine its precise configura- 
tion, while interesting from a scientific standpoint, 
requires special instruments and skill, but not al- 
ways at the command of the general physician. 

The damage being done by an enlarged prostate 
is by no means determined by its size. The author 
has very often seen enormous glands that were pro- 
ducing but little disturbance, and the other extreme 
as well. This condition is often best estimated by 
its consequence rather than by its size or shape. 

The advice that we are called upon to render in 
this situation carries with it weighty responsibility. 
We must call to our rescue here our character and 
professional strength, and remember all the condi- 
tions under which we are to proceed. 

The answers to the question that I now invite 
your attention fully cover the subject in its entirety, 
and I am safe in here promising you satisfactory 
return for your pains. 




s 




I3r 



W 



Fig. 4. Prostatic Hypertrophy. 

From Clay Model— Case of Dr. Bransford Lewis. 

Bilateral enlargement with obstruction from pedunculated 
intravesical growth. 



PROSTATIC HYPERTROPHY. 27 

JOHN A. WYETH, M. D., 
Of New York. 

(1) Sedentary pursuits tend to prostatic hyper- 
trophy. Active out-of-door life promotes normal 
secretion and excretion and assures nourishment of 
the tissues in general. 

(2) The phlegmatic and nervous suffer about 
equally if they follow sedentary pursuits and are 
troubled from indigestion and uric and oxalic acid 
diathesis. 

(3) Prolonged irritation of the bladder from 
any cause, together with irritation of the vascular 
system which is produced by a chronic uric acid 
and oxalic acid diatheses, and excessive use of the 
prostatic muscle are the chief causes of prostatic 
hyperthrophy. 

(4) Have never needed the cystoscope in diag- 
nosis, nor is any instrument necessary. The symp- 
toms, together with a digital examination, make the 
diagnosis easy. 

(5) Alcohol in any form is a factor in arterial 
irritation, and is also a factor in prostatic hyper- 
trophy. Constipation is also a factor. 

(6) In cases where operation for any reason is 
more than ordinarily dangerous the catheter life 



28 PROSTATIC HYPERTROPHY. 

may be advised. Especially true in the very aged, 
seventy and over. 

(7) Have not practiced ligation of the vasa def- 
erentia, and do not see any indication for this op- 
eration. 

(8) Have practiced this operation (castration) 
once with regret. Patient recovered, but was not 
improved. 

(9) Do not believe in Bottini's operation and 
have never practiced it. 

(10) No answer. 

(11, 12 and 13) Have practiced supra-pubic 
prostatectomy and perineal prostatectomy, but 
was not satisfied with either procedure as compared 
to a combination of both of these operations, which, 
in my opinion, is far preferable to the one or the 
other for these reasons: Supra-pubic incision into 
the bladder is a simple operation and does not add 
materially to the risk of a perineal incision. With 
the two incisions a dissection can be made rapidly 
and intelligently between the index finger of the 
hand. The drainage through the perineal wound 
secures a quick closure of the upper wound. The 
supra-pubic wound gives a better exploration and 
command of the bladder than the lower incision. 
No complications have arisen during or after any 



PROSTATIC HYPERTROPHY. 29 

of my cases. I have had no deaths following x>ros- 
tatectomy, but have operated only in comparative- 
ly few cases, lly opinion is that the operation is 
a valuable one. It should be performed early in 
the history of a case of prostatic hypertrophy. If 
the bladder becomes greatly overdistended or loses 
the power of emptying itself, and if it is nursed into 
helplessness by the use of the catheter, it is difficult 
to overcome this even after the obstruction has been 
removed. 

(14) None. 

(A) No answer. 



30 PROSTATIC HYPERTROPHY. 

NICHOLAS SENN, M. D., 
Of Chicago, III. 

(1) No difference. 

(2) No difference. 

(3) Antecedent urethral disease, venereal ex- 
cess and anything causing pelvic congestion. 

( 4 ) Nitze instrument useful in determining the 
part played by middle lobe in some cases. 

(5) Answered under question No. 3. 

(6) Systematic aseptic catheterization in cases 
in which radical operation is contra-indicated. 

(7) No. 

(8) Never have, and never will. 

(9) No. 

( 10 ) In perhaps a dozen cases with good pallia- 
tive results. 

(11) Wo answer to this question received. 

(12) In about twelve of fifteen cases. I prefer 
the operation combining the median incision with 
two lateral incisions representing in the outline an 
inverted capital Y. 

(13) Perineal operation preferred. 

(14) None. 

(A) The question as to the most feasible route 
by which to attack the diseased prostate has not 




Fig. 5. Median Perineal Incision. 




Fig. 6. Zuckerkandl's Incision. 



PROSTATIC HYPERTROPHY. 33 

been definitely settled. The supra-pubic method 
has many weighty advocates, and for a time was 
deemed the easiest, most efficient and safest. The 
perineal route has, however, been given a more ex- 
tended trial, and a very large experience appears 
to have decided in its favor. From an anatomic 
standpoint the perineal operation is certainly the 
most rational of the two, and will undoubtedly sur- 
vive the test of time. The removal of the enlarged 
prostate does not always meet all the indications 
in the case operated on. Few cases come to the 
surgeon in which the bladder is intact in conse- 
quence of the mechanical obstruction or infection, 
hence in the majority of cases it becomes necessary 
to establish free drainage after the removal of the 
prostate for the purpose of initiating a successful 
treatment for the coexisting complications. In 
making the external incision the surgeon must 
therefore have in view the exposure of the prostate 
to sight and touch as freely as can be done with 
safety, and to provide for free drainage of the blad- 
der and the perineal wound. Every surgeon who 
has had an extensive experience in perineal pros- 
tatectomy has learned that not all enlarged pros- 
tates can be removed by enucleation. There are 
cases in which the diseased organ must be removed 



34 PROSTATIC HYPERTROPHY. 

by morcellment. It is a rule in surgery which it is 
always well to bear in mind, and that is to operate 
as little as possible in the dark in important an- 
atomic localities, and this rule applies with special 
force to perineal prostatectomy. In obese subjects 
and in cases of very large prostates it is often ex- 
ceedingly difficult to bring the parts to be removed 
within reach of the index finger. It is under these 
trying circumstances that the operator will appre- 
ciate the advantages of an incision that will expose 
the prostate freely and bring it within easy reach 
of the finger or the instruments required for its re- 
moval. Very little is gained by attempts to ren- 
der the prostate more accessible by intravesical in- 
strumental pressure, and such efforts are by no 
means always harmless. The danger from hemor- 
rhage and accidental wounding of the peritoneum 
is reduced to a minimum by resorting to an incision 
that will expose the prostate in the freest possible 
manner to sight and touch. I have attempted to do 
this by combining the median incision with two 
lateral incisions representing in outline an invert- 
ed capital Y. The median incision is made in the 
usual way, laying bare the membranous portion of 
the urethra. The lateral incisions are carried from 
the lower angle of the median to a point half way 



\^ 





Fig. 7. Kocher's Incision. 



*% 




Fig. 8. Author's Incision. 



PROSTATIC HYPERTROPHY. 37 

between the anal margin and the tuberosity of the 
ischium, cutting through about the same structures 
as are involved in the lateral operation for stone in 
the bladder. The wound is next deepened largely 
by the use of blunt instruments and all hemorrhage 
arrested as it occurs, maintaining throughout the 
entire operation practically a bloodless field. This 
will give the operator an opportunity to recognize 
and identify the tissues as he proceeds with the dis- 
section. In this comparatively bloodless way the 
rectum is detached until the membranous portion 
of the urethra and the lower segment of the pros- 
tate can be distinctly seen and felt in the apex of 
the deep triangular wound. By using narrow flat 
deep retractors the rectum is pushed backward and 
the wound margins are retracted laterally, thus ex- 
posing freely the parts concerned in the next step 
of the operation. I then proceed as follows : In 
a grooved staff which is now inserted into the blad- 
der the membranous portion of the urethra is in- 
cised and the grooved director of Wheelhouse in- 
serted into the bladder. Withdrawing the staff 
and using the director as a guide the prostatic part 
of the urethra is dilated with the left index finger 
which, after it enters the bladder, serves as a blunt 
hook with which the prostate is drawn gently down- 



■™ 



38 PROSTATIC HYPERTROPHY. 

ward and foward into the wound. The capsule of 
the gland is next incised transversely and with the 
opposite index finger enucleation of the left lobe is 
commenced. This part of the operation is usually 
easy, sometimes difficult and not infrequently im- 
possible. Recklessness and undue violence are to 
be carefully avoided. Enucleation is often facili- 
tated by grasping the lower part of the prostate 
with my bullet forceps or some other grasping in- 
strument on which traction is made during the pro- 
cess of enucleation. I seldom attempt to remove 
the prostate in its entirety. Occasionally this can 
be done, but usually it will be found much easier 
to remove one lobe at a time. After the removal of 
the left lobe the right index finger is inserted into 
the bladder and the right lobe enucleated w^ith the 
left. If it is found impracticable to remove the 
prostate by enucleation, morcellement must be re- 
sorted to. The finger in the bladder is almost in- 
dispensable in operating by this method. With it 
the parts are brought within easier reach and it 
serves at the same time as a valuable guide for the 
use of the cutting and traction instruments. With 
grasping forceps portions of the gland are seized, 
when the necessary traction is made by an assistant 
while the surgeon does the cutting with blunt- 




/■■-. 



S: 




Fig. 9. 

Prostate and membranous portion of uretha seen on retraction 

of wound margins. 





X\ 






Fig. 10. 
Operation completed. 



/ 



PROSTATIC HYPERTROPHY. 41 

pointed scissors well surved on the flat. Complete 
prostatectomy in such cases is not necessary, but 
enough tissue must be removed to insure a free out- 
let for the urine and to guard against a recurrence 
of obstruction from the same cause. 

I am decidedly in favor of a preliminary cystot- 
omy in performing perineal prostatectomy, as it 
greatly facilitates the removal of the gland by enu- 
cleation or morcellement, and in the majority of 
cases it becomes a necessity for the treatment of 
complicating affections of the bladder. It is pre- 
ferable to incise the urethra and take advantage 
of such an opening into the bladder during the op- 
eration than to tear it accidentally, as is often done 
when operators undertake a perineal prostatect- 
omy without a preliminary cystotomy. I invari- 
ably drain the bladder by inserting a soft rubber 
drain with two oval fenestra near the vesical end. 
The drain is fastened in the lower angle of one of 
the lateral incisions with a suture which includes 
the outer margin of the wound. The perineal 
wound is drained with a strip of iodoform gauze 
which is brought out on the side of the rubber 
drain. The balance of the incision is sutured. The 
bladder is kept practically empty by siphonage by 
connecting the perineal drain with another piece 



42 PROSTATIC HYPERTROPHY. 

of rubber tubing, making the connection with a 
glass tube. Through this rubber drain the bladder 
can be washed out daily with appropriate antisep- 
tic solutions. The iodoform gauze drain should re- 
main for at least five or six days, as its presence in 
the wound is of the greatest value in preventing in- 
fection by leakage of septic urine. The bladder 
drainage must be continued until the condition of 
the urine is such as to warrant suspension of intra- 
vesical medication. 

The present technic of prostatectomy will be 
greatly improved, and its legitimate range of use- 
fulness will be widened with increasing clinical ex- 
perience and with a more definite knowledge of the 
etiology and pathology of senile hypertrophy of this 
gland. 



PROSTATIC HYPERTROPHY. 43 

BRANSFORD LEWIS, M. D., 

Of St. Louis. 

(1) Sedentary life favors it. 

(2) The obese. 

(3) Subacute chronic congestion or inflamma- 
tion. 

(4) Is of considerable service in determining 
the conformation of prostatic outgrowth. The 
Bransford Lewis cystoscope, with prism-telescope, 
enabling the observer to look slightly backward as 
well as at right-angle. 

(5) All influences contributing to prostatic con- 
gestion or inflammation favor development of pros- 
tatic hypertrophy; hence alcohol and constipation 
contribute their quota. 

(6) Cases in which not much residual urine, 
and infection absent; in which an operative treat- 
ment would be dangerous on account of accompany- 
ing conditions or diseases. Kegular catheterism 
and vesical irrigation ; internal antiseptics. 

(7) Yes, three cases ; no permanent benefit. 

(8) Yes, twice; no benefit. 

(9) Yes, about eighteen times; success in some 
cases, failure in others, intermediate results in 
others; the results dependent mainly on the con- 
formation of prostatic obstruction present. 



44 PROSTATIC HYPERTROPHY. 

To illustrate my position, I wish to call attention 
to a few points in the histories of several cases with 
which I have been personally acquainted. 

V. S., set. sixty-five years, came to my clinic in 
October, 1901, suffering from various effects of 
prostatic obstruction, chief among which was com- 
plete and absolute inability to urinate voluntarily, 
and this, notwithstanding the fact that perineal 
prostatectomy had been done on him six months 
before (on June C>, 1901) by an acknowledged au- 
thority in this mode of operating. The complete 
retention, relieved only by the regular passage of 
the catheter, had existed, the patient said, from 
the time of the withdrawal of the perineal drainage 
tube, seven days after the operation. A perineal 
fistula still existed, from the same procedure. 

Here was a case of complete failure of relief after 
removal of the prostate by an operator whose abil- 
ity and experience cannot be put into question. 

My cystoscopic examination seemed to reveal a 
projection from the posterior commissure, hanging 
somewhat into the bladder. With a doubt in my 
mind as to its probable efficacy in the case, which 
doubt I expressed to the class before whom I oper- 
ated, on November 20, 1901, I made one posterior 
incision, three centimeters in length, with the Freu- 



PROSTATIC HYPERTROPHY. 45 

denberg incisor. Because of the absence of pros- 
tatic tissue, on account of the previous operation, 
it was evident that care must be observed not to 
burn into perineal structures. No hemorrhage re- 
sulted; cocaine anesthesia, secured with my ure- 
thral tablet-depositor, was so complete that the pa- 
tient declared that there was no more pain than 
there was from an ordinary catheterism. He re- 
mained in the hospital three or four days, and was 
then about, as usual. Result, possibility of volun- 
tary urination, and reduction of the complete re- 
tention to seven ounces of residual urine. One 
month later, the same operation was repeated, with 
no more trouble to the patient ; and the net result 
was a further reduction of the residual urine to 
about four ounces, together with increase dfreedom 
in voluntary urination. This not being satisfac- 
tory to me — although a marked improvement over 
his condition for the previous five or six years — it 
seemed advisable to open supra-pubically, which I 
did before the class on January 8, 1902. A collar- 
ette of fibromucoid tissue completely surrounded 
the urethral orifice, and in just the position to fall 
together in a valvular manner and shut off the 
egress of urine when attempts at voluntary urina- 
tion were made. The more marked the contraction, 



46 PROSTATIC HYPERTROPHY. 

the tighter would the valve be closed. My poste- 
rior cautery incision was there, as shown in the 
model, but it had only bisected the posterior seg- 
ment of the collar, the flaps of which could still fall 
together and interfere markedly with the outflow 
of urine — although the groove thus made would 
probably allow of the leakage through it of a part 
of the urine. This accounted for the improvement 
noted after each of the electro-incisions (reduction 
in the residual urine at first to seven, then to four 
ounces) ; and also for the failure of the incision to 
give complete relief to the case. 

Through the supra-pubic opening, with a Paque- 
lin cautery I burned off the whole of the projecting 
mass, accentuating the cauterization on the poste- 
rior aspect, to secure as low a level as possible; 
nevertheless a considerable depression was still left 
in the bas fond, as I did not wish to open the pros- 
tatic urethra to secure an absolutely "low level," 
flush with the bottom of the bas fond. My chief 
object was to remove the obstruction, which was 
done in the manner described. Nothing was done 
bearing directly on the perineal fistula. It was 
considered that, with clearing up of the outlet, this 
would take care of itself. The bladder was drained 
supra-pubically for eight days. After the removal 



PROSTATIC HYPERTROPHY. 47 

of the tube, and even before the supra-pubic wound 
was closed, the bladder was able to expel in a good 
stream through the urethra a part of the urine or 
the irrigation fluid. Since the closure of the 
wound, he has urinated properly and regularly, in 
what he esteems a very delightful stream. He can 
irrigate his bladder without the aid of the catheter ; 
in fact, the catheter is now never used except for 
the purpose of testing the amount of residual urine, 
which has been reduced to one-half or three-fourths 
of an ounce. The frequency of urination is about 
normal (six or seven times in twenty-four hours). 
The patient has been able to resume his occupation 
of carpentering after an interruption of one year. 
He relates that previous to the prostatectomy, he 
had been forced to use the catheter regularly for 
nearly eight years, carrying it in his pocket for that 
purpose ( from March, 1894, to November, 1901 ) . 

Case 2. — W. D. set. sixty-five years, was turned 
over to my care at the City Hospital, by my friend, 
Dr. Metert, who, with his internes at that time, is 
familiar with the subsequent developments. 

The patient had suffered from troubles connect- 
ed with urination for four or five years previously. 
His general health and strength were markedly re- 
duced, so that he was very feeble, looking much old- 



48 PROSTATIC HYPERTROPHY. 

er than he really was. He was passing urine about 
thirty-five times in twenty-four hours, as often at 
night as in the day time, harassing him with loss 
of sleep as well as much actual suffering. His 
urine was of light straw color, low specific gravity 
(1.010), and contained albumin and casts, indica- 
tive of involvement of the kidneys. Cystitis was 
present. Residual urine was about twenty-eight 
ounces. A metal catheter of ordinary curve was 
obstructed, while one of long prostatic curve went 
in easily. Because of the enfeebled condition of 
the patient, and the renal complication mentioned, 
a more radical operation than the Bottini was 
deemed dangerous ; and it was considered necessary 
to undertake even that with the utmost caution. 
The Bottini was clone on January 27, 1898, under 
cocoaine anesthesia, only one (posterior) incision 
being made in order to avoid severity as much as 
possible. It was ten days afterwards before no- 
ticeable improvement began, but it was progressive 
thereafter, so that in a month he was urinating 
freely and in a good stream ; and instead of thirty- 
five times in the twenty-four hours, it was only 
seven or eight times. The residuum had been re- 
duced to about two ounces. The patient's general 
and renal conditions had both improved materially. 



PROSTATIC HYPERTROPHY. 49 

I was desirous of showing him at the medical so- 
ciety, to which he consented, with the request, how- 
ever, that we wait until he could be operated on for 
a large inguinal hernia, of which he was the bearer. 
We waited. He was turned over to another con- 
sulting surgeon who operated for the hernia. The 
wound became infected, resulting in gangrene there 
and also in the intestines and lungs. His death 
soon after enabled me to get a good specimen. 

As is usual after maceration in alcohol, the tis- 
sues have shrunk somewhat, so that they do not ap- 
pear exactly as they did when fresh ; but the mod- 
erate enlargement of the prostate is evident, like- 
wise the groove posteriorly and to the right, made 
by the incisor. 

The depth of this groove is only evident when 
we oppose the parts as they were seen before the in- 
cision was made, when the narrowing of the outlet 
is seen to be marked. 

Dr. Willard Bartlet, who made the post-mortem 
examination, made the following annotation re- 
garding it : "The prostate shows both lateral lobes 
hypertrophied. The wound left by what the clini- 
cal history terms 'Bottinf s operation/ is complete- 
ly healed, leaving an orifice to the right of the me- 
dian line which will easily admit an ordinary lead 



50 PROSTATIC HYPERTROPHY. 

pencil into the prostatic urethra, and evidently 
furnished a free outlet for the urine." The ob- 
structive condition in this case was a bar forma- 
tion at the posterior commissure ; the incision had 
severed it and opened a groove through which the 
urine could pass with only slight impediment. 

(10) Practiced it only for the temporary bene- 
fit it affords, which is often very valuable, permit- 
ting recuperation for a more effective operation. 

( 11 ) Three times ; good result in each case. 

(12) Eight times; excellent success. The in- 
verted Y incision is preferable. 

(13) Each operation, in selected cases; but 
with other things favorable, the perineal prostatect- 
omy gives most secure results. 

(14) In one case, in which linear perineal in- 
cision did not give sufficient space, a small tear 
was made through the anal margin, and a consti- 
pated movement of the bowels two days later en- 
larged it for an inch into the anterior rectal wall. 
The perineal wound healing, left a urethro-rectal 
plastic operation. 

(A) Summing up the points favorable to the 
three operative procedures especially considered in 
this discussion, we have : 

Favorable for the Supra-Pubic Route. — (a) 



PROSTATIC HYPERTROPHY. 51 

General enlargement of the prostate, with extreme 
intra- vesical projection of the median or lateral 
lobes, diminishing their accessibility from the peri- 
neum. (6) Marked pednnculation of the intra- 
vesical tumors, with absence of obstruction from 
other sources. 

Favorable for the Perineal Route. — (a) Gen- 
eral hypertrophy, involving the median and lateral 
lobes, without extreme intra- vesical projection. 
(6) Large or very thick bar formation; marked 
compression of the urethra between the enlarged 
lateral lobes, (c) Excessive development of the 
prostate in the direction of the rectum, (d) In 
most cases, where the patient is in good general con- 
dition and there is not a special indication favoring 
one of the other procedures. 

Favorable for the Bottini. — (a) Cases of ex- 
treme debility, unable to stand one of the severer 
operations, (b) Cases of bar or medium sessile 
obstruction, of not too great dimensions, (c) In- 
complete collar formation, (d) Horwitz says it 
should be employed as a prophylatic against fur- 
ther obstructive hypertrophy, at the beginning of 
catheter-life. 



52 PROSTATIC HYPERTROPHY. 

J. B. MURPHY. M. D. f 

Of Chicago, 

(1) I have not been able to discern that occu- 
pation plays any part whatever in the production 
of prostatic hypertrophy. 

(2) About equal. 

(3) I am unable to determine, from my experi- 
ence, any etiologic factor in the production of pros- 
tatic hypertrophy. I believe those given in the text- 
books are erroneous and the result of imagination 
rather than the close observance of facts. 

(4) The cystoscope has been of no service. 

(5) None. 

(6) I advise palliation in cases of temporary 
obstruction for urinary retention. Consists of use 
of hot baths, large quantities of distilled water, 
opium and belladonna suppositories, avoidance of 
catheter or bladder irrigation. 

(7) No. 

(8) Yes. With pronounced effect in two cases, 
and no effect in the remaining. 

(9) No. I have not performed the Bottini. 

(10) I practiced supra-pubic drainage for ten 
years, in a large number of cases, at the Alexian 
Brothers' Hospital. The results were very unsat- 



PROSTATIC HYPERTROPHY. 53 

isfactory, for two reasons: first, they were not re- 
sorted to until the cases were extreme ; second, I be- 
lieve it is not an efficient treatment. 

(11) Probably fifteen or twenty times, with 
very unsatisfactory results. My Alexian Brothers' 
Hospital records are not at my disposal at the pres- 
ent time, and, therefore, I cannot give the exact 
number. 

(12) Twenty-nine times, with perfect success. 
The crescent or "A" shaped incision gives the best 
space. 

( 13 ) The perineal operation, as described in the 
Journal of the American Medical Association about 
one year ago. 

(14) None during operation. I have been im- 
pressed by the care that must be exercised to avoid 
the rectum, with very large prostates. 

Post-operative complications. — One case, apo- 
plexy two weeks after operation; patient was sit- 
ting up reading newspaper. In another there oc- 
curred a peri- and endocarditis, rheumatic, five 
weeks after operation, when the patient was prac- 
tically well and about to go home. 

(A) I believe that the operation of the future 
will be prostatectomy by the perineal route, "A" 
shaped incision, removal of prostate from the blad- 



54 PROSTATIC HYPERTROPHY. 

der wall from above downward, with removal of the 
floor of prostatic urethra ; that it should be resorted 
to early, before the manifestations of sepsis; that 
prostates of any size may be removed through the 
perineum ; that drainage of the bladder is not nec- 
essary for longer than two weeks ; that with experi- 
ence and care the operation can be performed safely 
within thirty minutes ; that the "A" shaped incision 
allows as much space for the removal of the pros- 
tate as the vagina for the removal of the uterus; 
that the result is a practical restoration of the nor- 
mal conditions of the bladder ; that there is perma- 
nent disability for intercourse. 



PROSTATIC HYPERTROPHY. 55 



ORVILLE HORWITZ, M. D., 

Of Philadelphia, Penn. 

( 1 ) So far as I have been enabled to ascertain — 
none. 

(2) There seems to be little or no difference. 
The condition is rarely found in the negro. 

(3) Not ascertained. 

(4) The cystoscope is of much value in portray- 
ing the condition of the bladder and greatly aids 
the surgeon in determining the expediency of per- 
forming a Bottini operation, or a prostatectomy. 

The condition of the bladder enables the operator 
to decide whether or not a radical operation will be 
followed by relief of the annoying vesical symp- 
toms. 

The most satisfactory instruments that have been 
employed by the writer for diagnostic purposes is 
the posterior urethroscope of Swinburn and the 
Bransford Lewis cystoscope. 

(5) The habits of individuals do not appear in 
any way to tend to the formation of hypertrophy 
of the prostate gland. Constipation is frequently 
an annoying accompaniment associated with it; it 
seems to be caused by the enlargement of the gland, 
as the radical operation is often followed by its 



56 PROSTATIC HYPERTROPHY. 

disappearance. This has been especially noticed 
to take place after the Bottini operation. 

(6) Palliative treatment is reserved for those 
cases who are advanced in years in whom the ob- 
struction has existed for a long period of time and 
exhausted from pain, suffering and loss of sleep. In 
old men whose resisting power is at a low ebb, where 
the bladder is hopelessly damaged, and in those 
who show marked signs of general sclerosis; as 
rigid vessels, arcus senilis, polyuria, hyaline casts 
or pyelitis. 

The treatment advocated in this class of cases de- 
pends on the physical condition of the patient, the 
character of the prostatic overgrowth, the state of 
the bladder and kidneys. It may be summarized 
as medical; hygienic; systematic catheterism; rest 
in bed for several weeks, the bladder drained by 
means of continuous catheterism; irrigation of the 
bladder with appropriate sulutions, or instillations 
of various remedies; rectal injections; permanent 
drainage by means of supra-pubic cystotomy; in 
some instances a Bottini operation in conjunction 
with periodical catheterism. In patients who suf- 
fer from recurring attacks of orchitis from the 
passage of a catheter, vasectomy is performed. 

( 7 ) Twenty-eight individuals were submitted to 



PROSTATIC HYPERTROPHY. 57 

this operation, all of whom, with the exception of 
six, were over sixty-three years of age, and the sex- 
ual functions of all but six were in abeyance. Vasec- 
tomy was performed whether the enlargement of 
the prostate was glandular or fibrous in character. 
No deaths resulted from the operation. The re- 
sults obtained lead me to the following conclusions : 

(a) As a curative measure vasectomy is of little 
value, and is not to be recommended. 

(b) The operation appears to be most effective 
when performed on patients between fifty and sixty 
years of age, in whom the prostatic enlargement is 
of the soft glandular variety. The genital organs 
of patients of this age are usually in a healthy con- 
dition, and the individuals usually object to any 
operation that is liable to interfere with their sex- 
ual functions. 

(c) The operation is serviceable in those cases 
where the physical condition of the individual ren- 
ders him unfit to undergo surgical procedure, who 
will not submit to a more serious proceeding, who 
has to depend upon the frequent use of the catheter 
or who suffers from periodical attacks of orchitis. 

(d) Sexual vigor is not diminished by the di- 
vision of the vasa deferentia. 



58 PROSTATIC HYPERTROPHY. 

(e) Atrophy of the testicle does not result from 
the operation. 

(8) In forty-four cases bilateral orchidectomy 
was performed, irrespective of the character of the 
enlargement of the prostate gland. All the pa- 
tients were men in advanced years, whose sexual 
powers had disappeared ; in the majority the heart 
was feeble, the arteries athermomatous, and they 
all suffered from general debility, the result of the 
wear and tear of prolonged misery. In a few, a 
far-advanced diseased condition of the bladder and 
kidney existed. Several had suffered from frequent 
attacks of retention of urine ; catheterism was nec- 
essary in all; the insertion of the instrument was 
difficult and painful. In this class of patients pro- 
longed anesthesia, with any serious operation in ad- 
dition, would in all probability prove immediately 
fatal. 

(a) In selected cases, bilateral castration will 
always hold a place in genito-urinary surgery as a 
means of removing the obstruction caused by pros- 
tatic hypertrophy. 

(&) The operation is indicated in men of ad- 
vanced years, whose sexual powers are lost, the 
overgrowth of the prostate being purely glandular 
in character; or who have reached that period of 



PROSTATIC HYPERTROPHY. 59 

life where the passage of a catheter becomes difficult 
and retention of urine not an uncommon occur- 
rence; or an advanced diseased condition of the 
bladder and kidneys does not preclude a serious 
operation. 

(c) When the prostatic enlargement is fibrous 
in character no benefit is derived from the opera- 
tion, and its employment under these circumstances 
is not to be recommended. 

(d) The primary effect of castration on the 
glandular prostatic hypertrophy is first to relieve 
congestion, and secondarily to cause atrophy. 

(e) When the prostatic enlargement is fibrous 
in character no benefit is derived from the operation 
and its employment under these circumstances is 
not to be recommended. 

(/) Orchidectomy in very old subjects with ex- 
tensive disease of the bladder and kidney is attend- 
ed by a large mortality, and is a very serious opera- 
tion. 

(9) Seventy-nine patients, between the ages of 
forty-nine and eighty-one years, were operated on 
by me by the 'Bottini method." One death resulted. 
According to Dr. Fredenberg (Berlin), the most re- 
cent statistics show that good results can be looked 



60 PROSTATIC HYPERTROPHY. 

for in 86.63 per cent of cases ; failure in 7.6 per cent; 
mortality in 4.5 per cent. 

For convenience of description the cases that I 
have treated may be divided into three groups : 

First. — Comprising individuals who were com- 
mencing to suffer from the effects of prostatic ob- 
struction, and who required the daily use of the 
catheter. These were between the ages of forty- 
nine and sixty-one. Heretofore this class of pa- 
tients would have been placed upon what is known 
as the "Palliative Method of Treatment." Of six- 
teen who submitted to the operation before the sec- 
ondary pathological changes that follow prostatic 
hypertrophy had taken place, all made prompt re- 
covery; the period of convalescence varied from 
four to eighteen days. When operating on patients 
at the beginning of prostatic hypertrophy, the gland 
as a general rule being but slightly enlarged, a pros- 
tatic incision with a smaller blade should be em- 
ployed than that which is used in more advanced 
cases. The Bottini operation performed early may 
be regarded as a radical method of treatment re- 
sulting most favorably. It would seem as though 
the time had passed when the physician is satisfied 
to advise his patience to use the catheter daily and 
patiently wait until the obstruction becomes so 



PROSTATIC HYPERTROPHY. 61 

grave that some radical surgical procedure is nec- 
essary to give relief. 

Second. — The second group of cases comprises 
those where the obstructive symptoms have existed 
for a lengthened time, where the bladder is begin- 
ning to be involved, and is in the process of under- 
going pathological changes. Catheterism is dailj- 
requisite, the physique of the individual being still 
in good condition. This group is portrayed by eight 
operations, the individuals being between fifty-nine 
and sixty-three years of age; the period of conval- 
escence, including necessary after-treatment, was 
from two weeks to four months. Of the number 
operated upon five were cured, two were improved, 
and one was benefited, so far as residual urine was 
concerned, which was owing to the bladder being 
atonied and paralyzed ; the catheter was readily in- 
serted, the prostatic spasm having been entirely re- 
lieved by the operation. A slight amount of resid- 
ual urine, rendering the use of the catheter neces- 
sary. 

To the third group belonged men more advanced 
in years, their ages ranging between sixty-five and 
eighty-one years, in whom prostatic hypertrophy 
had existed for a lengthened period, who had 
reached what is known as the "Break-down of Cath- 



62 PROSTATIC HYPERTROPHY. 

eter Life," whose general health was below par, 
with atheromatous degeneration of the blood ves- 
sels, and polyuria, together with damaged bladder 
and kidneys, and who had suffered from repeated 
attacks of retention of urine. A large amount of 
residual urine existed in each instance. All were 
in too poor a condition to withstand a capital oper- 
ation, and before the introduction of Bottini's 
method would have had to rest satisfied with some 
palliative procedure. 

Out of the number of patients operated upon, in 
three there was a slight tendency to the recurrence 
of the obstructive symptoms at the end of six 
months, making a second operation necessary. Two 
had occasional attacks of congestion of the prostate 
gland, associated with temporary retention of 
urine, following prolonged dissipation and expos- 
ure. From the results obtained by the experience 
that I have recorded, I feel that I am warranted 
in forming the conclusions here set forth : 

(a) Success following the Bottini operation de- 
pends on having perfect instruments, a good bat- 
tery, the necessary skill, and the employment of a 
proper technique. 

(b) In suitable cases the Bottini is the safest 



PROSTATIC HYPERTROPHY. 63 

and best radical operation thus far advised for the 
relief of prostatic hypertrophy. 

(c) It is often very efficacious in advanced cases 
of obstruction as a palliative measure, rendering 
catheterism easy and painless, relieving spasm, 
lessening the tendency to constipation, and improv- 
ing the general health. 

(d) It is of especial service in the beginning of 
obstructive symptoms, due to hypertrophy of the 
prostate gland, and may be regarded as a means of 
preventing catheter life. 

(e) It is indicated in all forms of hypertrophy 
except where there is a valvular formation, or 
where there is an enormous overgrowth of the three 
lobes associated with tumor formation giving rise 
to a pouch, both above and below the prostate 
gland, in cases of a massive enlargement of the lat- 
eral lobes or when intra-urethral growths exist. 

(f) Where the bladder is hopelessly damaged, 
together with a general atheromatous condition of 
the blood vessels, associated with polyuria, results 
are negative. 

(g) Pyelitis is not a contra-indication to a re- 
sort to the operation. 

(10) Have practiced suprapubic drainage in 
seventy-six cases. It is doubtless the most satis- 



64 PROSTATIC HYPERTROPHY. 

factory palliative operation that can be resorted to. 
Mortality about 2 per cent. 

(11) Have practiced superpubic prostatectomy 
in fifteen cases ; three deaths. Kesults excellent. 

(12) Have performed perineal prostatectomy 
in thirty-one cases. Results: Fourteen cured; 
seven much improved ; four slight benefit ; one un- 
improved ; five deaths. Used median incision. Bry- 
son's technique; perineal prostatectomy gives low- 
er mortality, less hemorrhage, with better drainage ; 
no injury to the neck of the bladder. A shorter 
time is required to perform the operation. Ninety- 
five per cent of hypertrophy of the prostate gland 
can be removed by means of a perineal incision. 
The writer recently removed a gland weighing an 
half a pound by means of the median cut. 

(13) A suprapubic prostatectomy is a chosen 
operation in cases of obstruction, due to valve for- 
mation, with a long-standing cystitis ; as it is like- 
wise where obstruction is due to a collarette, when 
a partial resection of the gland may be performed. 

Prostatectomy should be performed only in cases 
that have been carefully selected. Many are fit 
only for palliative operations. In many instances 
it is wise to perform a preliminary supra-pubic cys- 



PROSTATIC HYPERTROPHY. 65 

totomy, drain the bladder for some time until the 
patient's condition will warrant a prostatectomy. 

(14) No unexpected complications have ever 
arisen in the practice of the writer during, or fol- 
lowing, the operation for prostatic hypertrophy. 
In two instances recto-urethral fistula formed on 
or about the twelfth day ; owing probably to the em- 
ployment of metal drainage; drainage is now main- 
tained by means of a soft rubber rectal tube, caliber 
40 m., after perineal prostatectomy. In one in- 
stance secondary hemorrhage supervened on the 
second day. One patient died of secondary shock 
twenty-four hours after operation. A perineal op- 
eration fistula resulted in one case, requiring a 
second, operation. 

In several cases dribbling of urine has followed 
a perineal prostatectomy, which condition has 
lasted from six months to a year. In one case a 
tendency to the formation of a urinary structure 
was developed at the neck of the bladder necessitat- 
ing the use of bougies. 

(A) No answer. 



66 PROSTATIC HYPERTROPHY. 



AUGUSTUS CHARLES BERNAYS, M. D., 
Of St. Louis. 

(1) The statistics I have seen do not decide this 
question. I have an idea that these factors play but 
a very insignificant part. See next answer. 

( 2 ) Do not think these are pertinent questions ; 
do not go much on homeopathic or temperamental 
pathology. 

(3) Etiology. — This is a short summary of 
what is known at present about etiology. The ques- 
tion of how much clap and structure contribute to 
the cause of prostatic hypertrophy is not yet solved. 

Up to the present time the etiology of prostatic 
hypertrophy has not been cleared up. A completely 
satisfactory explanation of the process has not been 
found. Sir Henry Thompson defined it as an 
"idioplastic tumor" in his lectures, which I had the 
great pleasure of hearing. Enlargements of or- 
gans during the early and middle life partake large- 
ly of an inflammatory nature or are found to be 
small cell infiltrations. Knowing that old age 
somewhat inclines toward or favors the develop- 
ment of tumors, we are not surprised to find that a 
part of the sexual system may show a non-inflam- 
matory enlargement at a time when this system, in 



PROSTATIC HYPERTROPHY. 67 

all its other organs and in its functions, is under- 
going a retrograde metamorphosis and is being 
more or less put to rest. However, let us remem- 
ber that Sir Henry's definition is not explanatory 
in any sense and leaves the etiology of our subject 
in the dark. 

Reginald Harrison seems to think that the hyper- 
trophy is caused by overexertion or overwork of the 
organ the function of which he conceives to be that 
of aiding the bladder in the evacuation of its con- 
tents. He thinks that the main purpose of the 
prostate is to furnish a muscular support "primar- 
ily to the bladder and its contents and secondarily 
to the adjacent parts/' and thus seems to regard en- 
larged prostate as a form of compensatory hyper- 
trophy similar in its etiology to the well-understood 
hypertrophies of the muscular walls of the heart. 
Guy on' s theory is opposed to this view, he regard- 
ing the hypertrophy as due to arteriosclerosis of the 
urogenital tract. 

White agrees with Velpeau that in this disease 
we have an analogue of the fibromyomatous uterus. 
Sir Henry Thompson also favors this view, and I 
also think, that the myoma of the prostate is anal- 
ogous to myoma uteri,* and I think that it may be 
referred to developmental or congenital cell-nests 



68 PROSTATIC HYPERTROPHY. 

which lie dormant in early life and are only incited 
to late enlargement by the incidents accompanying 
the functions of the genito-urinary organs in health 
and in disease. 

Thus, we must admit that the etiology of pros- 
tatic enlargement is not understood and that the 
speculations which we have before mentioned are 
only a little more respectable than those specula- 
tions which bring diet, occupation, modes of living, 
abstinence and indulgence, sexual habits, gout, 
rheumatism or gonorrhoea into direct or indirect 
etiological relation with the disease. 

In most of the diseases in which etiology is not 
cleared up the pathology is also incomplete. 

(4) In a few cases where I have used or had 
an expert use the cystoscope, it did not add mate- 
rially to our knowledge of the intravesical condi- 
tion. 

( 5 ) See answer to Question 1. The same holds 
good here. 

(6) In the vast majority of cases "catheter 
life" will have to answer for a palliative measure 
until a radical operation is so perfected that its 
dangers are reduced to a figure much lower than 
at present. 

(7) No. I consider it a practice based on false 



PROSTATIC HYPERTROPHY. 69 

premises. I do not know of a case that was cured. 
Have treated a dozen or more which were castrated 
by others and were not permanently benefited. 

(8) No. 

(9) I was called to make a perineal section in 
one case where infiltration of urine and sloughing 
of the scrotum followed a Bottini operation. Have 
never done Bottini myself. 

(10) The following table gives the results of 
my supra-pubic drainage work and the fate of the 
patients so far as known to me: 

Cured 1 

Leading a catheter life, as before drainage 8 

Operated on after Bottini and improved 2 

Operated on after Bottini and not benefited .... 1 
Operated on after Bottini and died on the third 
day after the cautery of septic pyelonephritis 1 

Operated on by perineal prostatectomy 2 

Of these one died of pyelonephritis on the 
fourth day after operation, the other seems 
to be cured. 
One patient is now being drained supra-pubical- 

ly for the second time 1 

Died of pyelonephritis, senile gangrene or pneu- 
monia 6 

Disappeared and condition unknown 4 

Total 26 



70 PROSTATIC HYPERTROPHY. 

All of those whom I drained supra-pubically 
were eloquent in their praises of the relief afforded 
to them. The patient who died of embolus was en- 
tirely relieved of his usual trouble and suffering 
before he died, and I am not sure that this death 
ought to count for much against the supra-pubic 
operation. I regard the supra-pubic drainage as 
the best method of giving temporary relief to those 
patients who are not willing or not in condition to 
undergo prostatectomy. The cystitis can be cured 
by drainage and will not always return after the 
drain-hole is closed. 

(11) Once, in an old man (eighty-one years) at 
St. Mary's Hospital, died the next day — think he 
bled to death. 

(12) Twice. Both cases were benefited; one 
seems almost cured of his troubles, if I may use this 
expression. 

(13) Ferguson's or Bryson's operation, which 
are really very similar to each other in actual prac- 
tica 

( 14 ) If you mean prostatectomy, I can say that 
I had no trouble in my two cases. 

(A) See above. 



PROSTATIC HYPERTROPHY. 71 



GRANVILLE MAC GO WAN, M. D., 

Of Los Angeles, Cal. 

(1) None whatever. The people I have treated 
for prostatic hypertrophy came from all walks of 
life. They have been farmers, artisans, merchants, 
bankers, stockraisers, mechanics, soldiers, miners, 
tailors, sailors, day laborers, preachers, physicians 
and railroad men. 

(2) To the best of my recollection, there have 
been more individuals who might be classed as nerv- 
ous and fewer classed as abese. 

(3) All prostates that I have removed, upon ex- 
amination present macroscopical and microscopi- 
cal evidences of inflammation. But whether in- 
flammation has been the cause of the hypertrophy 
or an accident arising out of the strains and in- 
juries to the distende dand dilated blood vessels 
by foecal accumulations, catheters, or sexual ex- 
citement, it is impossible to say. 

I confess that I have not been able to evolve an 
explanation, satisfactory to myself, as to why cer- 
tain men who are in, or have passed, the sixth de- 
cade of life, develop prostatic hypertrophy while 
others escape entirely. If this were the fate of all 
old men, it might be easy to understand it. Or if 



72 PROSTATIC HYPERTROPHY. 

it followed the transgression of certain hygienic 
laws, one might comprehend it. But careful in- 
quiry into every case that has presented itself, num- 
bering now many hundreds, has failed to give any 
definite reason for the occurrence of the trouble 
either in the habits or the occupation of the in- 
dividuals. 

(4) The cystoscope has frequently been of great 
service to me in determining the advisability of 
doing a supra-pubic or combined prostatectomy in 
place of the less dangerous and more simple pe- 
rineal operation, which I prefer. If there are ob- 
structive tumors within the bladder, outgrowths 
from the prostate projecting into the lateral or su- 
perior quadrants of the bladder neck, their pres- 
ence can only be determined by the cystoscope. In 
such cases the perineal operation is only a waste of 
time. But if there are no such tumors present, it 
is foolish and unnecessary to do a supra-pubic or 
combined operation. 

Cystoscopic evidence is also sought by me to de- 
termine the probable value of the Bottini opera- 
tion in a given case. If the obstruction is posterior 
and central, a so-called middle lobe growth, in most 
instances a prostatotomy by this method is much 
less dangerous and quite as satisfactory in its re- 



PROSTATIC HYPERTROPHY. 73 

suits, at least for a long time, as a prostatectomy 
would be. If the growth is fibroid or myomatous, 
or these elements predominate in the hypertrophy 
to an extent that precludes a successful enucleation, 
the Bottini is the method of choice. I use a Nitze- 
Albarran, or Mtze, or Casper cystoscope for these 
examinations. 

( 5 ) I do not believe that the use of alcohol, or 
its abuse, is responsible for prostatic hypertrophy. 
Many of my clients have been mildly moderate 
drinkers or total abstainers, if any can be con- 
sidered a total abstainer in America, where the ma- 
jority of people who do not drink at their homes, in 
saloons or clubs, get their alcohol in patent medi- 
cines without being aware that they are drinking. 
My experience is that constipation is more to be 
considered a result of the hypertrophy of the pros- 
tate and the consequent rectal obstruction, than it 
is to be the cause of it, though, unquestionably, in 
many instances the presence of constipation in- 
duces attacks of acute inflammatory edema of the 
prostate with retention. 

(6) (a) In all cases at the commencement of 
the trouble and up to the advent of catheter life. 
My reasons for this are: 1. That all surgical op- 
erations about the neck of the bladder are serious 



74 PROSTATIC HYPERTROPHY. 

ones, the outcome of which cannot be positively pre- 
dicated. 2. There is always a possibility that the 
man may lose his life from the operation. 3. The 
object may not be attained, or a fistula may form 
after it. 4. It is not right to submit a man, who 
still has sexual potency, to one of the mutilating 
operations simply because he is certain at some in- 
definite time in the future to be no longer able to 
pass water. 

( b ) In the case of the individuals who are well 
advanced in the disease, but who are easily cathe- 
terized, intelligent and tractable, the use of the 
catheter may be pursued so long as such individ- 
uals are comfortable. 

(c) In people who suffer from hemophilia. 

(d) In those who have serious valvular lesions 
of the heart, accompanied by great muscular weak- 
ness. 

(e) And, most important, in those who are un- 
able to secrete a reasonable quantity of urea in each 
twenty-four hours — and what I consider a reason- 
able daily quantity of urea is from 15 to 25 grams. 

(f) When the hypertrophy is cancerous or com- 
plicated by tuberculosis. 

In the years of commencing prostatism, the pal- 
liative measures I resort to are those in common 



PROSTATIC HYPERTROPHY. 75 

use, consisting principally of massage and the care- 
ful use of the Benique or Guyon sounds or the Koll- 
man curved dilator, with hygienic measures, and 
the interdiction of horseback riding or prolonged 
sexual excitement. After the advent of catheter 
life; prolonged drainage, according to the princi- 
ples taught by Sir Everard Home and Felix Guyon, 
I have very frequently found sufficient, giving bet- 
ter results than vasectomy, and quite as good, as a 
rule, as castration. 

In classes c, d and e, regular catheterization, fol- 
lowing the excellent rules laid down by Edward 
Martin, is the best method of procedure. 

If the condition becomes intolerable, it is better 
to resort to the Bottini operation than attempt a 
prostatectomy. In class / a Bottini prostatectomy 
or supra-pubic drainage by the Senn or Depezzer 
tubes I have found very satisfactory. 

(7) Yes. I cannot say how many, but certain- 
ly more than twelve, with no permanent results of 
any kind at any time, and with no more temporary 
benefit than I have derived many times from pro- 
longed urethral drainage accompanied by instilla- 
tions or vesical lavage by solutions of silver nitrate. 

(8) Yes. Twenty times. In three instances 
with apparently perfect success. In nine cases 



76 PROSTATIC HYPERTROPHY. 

with varying degrees of benefit. Eight times without 
relief of any kind. Upon one of these cases I did a 
prostatectomy three years afterwards. I did not 
notice any diminution in the prostate in the inter- 
val. I had one of the original cases operated by 
Dr. Haynes, under my care and observation for sev- 
eral years. For a year following the castration he 
seemed to be greatly benefited, then the prostate in- 
creased in size, vesical catarrh became marked and 
calculi formed, requiring lithotrypsis twice in two 
years. The obstruction increased to a point where 
it was necessary to use the catheter every fifteen or 
twenty minutes, and the individual finally died 
from the disease. Out of the twenty there were 
four deaths directly attributable to the operation. I 
regard castration as more dangerous, and not to be 
compared as in beneficial results with perineal pros- 
tatectomy. 

(9) Yes. Twenty-nine times. Very good. 
Many practical cures. I mean by that, the ability 
to empty the bladder either entirely or with a resid- 
ual not to exceed 30 c. c. Four of my earlier cases 
died, but one of these was due to carelessness upon 
the part of an assistant in controlling the current, 
and another directly to my own ignorance and in- 
experience at that period. 



PROSTATIC HYPERTROPHY. 77 

One was a paralytic and leaked continuously, 
and wore a urinal from the time of the operation 
until his death, three years afterwards ; but, as he 
said, he was much better off in this condition than 
he had been with his retention, when he had been 
obliged to be painfully catheterized every half hour 
hour. The others were all greatly benefited or 
permanently cured. Three subsequently, when 
their general health had improved through the pal- 
liation of the Bottini drainage, submitted to pros- 
tatectomy. One of these was cancerous and died 
from secondary hemorrhage incident to the pros- 
tatectomy. I did not find the Bottini scars inter- 
fered in any marked way with these enucleations. 

One, a man of seventy-four years who was so 
weak and ursemic that I did not dare to do a pros- 
statectomy on him, had an apparently perfect re- 
sult for eighteen months subsequent to the Bottini. 
Then, the obstruction returning, I did a perineal 
prostatectomy upon him without relief, and three 
months afterwards was compelled to cut him supra- 
pubically, and removed a fibrous outgrowth, which 
hung down from the left upper segment of the pros- 
tate into the bladder neck, with difficulty by the 
Fuller rongeur. He is now perfectly well, has con- 
trol over his bladder and has restored sexual power. 



78 PROSTATIC HYPERTROPHY. 

The complications I have noticed have been epi- 
didymo orchitis in five cases, perineal abscess in 
two cases, perivesticultis in another from a perfor- 
ation of the bladder wall by an anterior burn, and 
once fatal primary hemorrhage, due to an overheat- 
ed cautery in a hemophile. 

(10) Eight times. Twice for cancerous hyper- 
trophy, using the Senn drainage tube with very 
good results, the individuals obtaining perfect re- 
lief from pain and living comfortably for nearly 
two years. Three times by the Hunter McGuire 
method with some relief and comfort. But these 
persons did not remain long under my observation. 
Three times by the Depezzer supra-pubic retention 
catheters. These latter were cases in which cathe- 
trization was impossible or not feasible, and drain- 
age was required to avoid suffering, and to prepare, 
is possible, for subsequent prostatic operations 
They were all feeble old men, who could not stand 
the shock of any radical operative measures. They 
all subsequently died within less than six months 
after such drainage was instituted, but were quite 
comfortable while they were alive. 

(11) Twenty-one times. Deaths 5, cures 14, 
relief 2. 

(12) Twenty-eight times. Deaths 4, cures 21, 



PROSTATIC HYPERTROPHY. 7 9 

relief 3, including two which may later be classed 
as cured. 

The Chicago incision or inverted Y. 

(13) Median perineal prostatectomy, the incis- 
ion is made directly into the membranous and 
prostatic urethra, the capsule of the prostate 
opened by a blunt capsule knife from the urethra, 
first on one side and then on the other, the tumors 
enucleated usually by the fingers alone. The pa- 
tient is placed in the position of extreme flexion 
of the lower limbs upon the pelvis, the table being 
slightly in the Trendelenberg position. This posi- 
tion was first suggested and practiced by Dr. George 
Goodfellow, of Tucson, and San Francisco, and 
adds greatly to the ease of the operative procedure. 

In the greater number of instances prostatic ob- 
structions can be removed by this method more 
speedily, with less damage to the structures of the 
bladder neck, with less hemorrhage and consequent 
shock, and with less space for subsequent infection 
than by any other operation. Further, there is less 
prolonged confinement to the bed and the house, 
and less wetting of the patient. If all of the ob- 
structions cannot be removed satisfactorily, espe- 
cially in intravesical ones situated in the floor of the 
bladder, more room can be obtained by a section 



80 PROSTATIC HYPERTROPHY. 

of the floor of the prostatic urethra and the neck 
of the bladder and the bar, if there be one beyond it, 
by careful work with a Blizzard in the median line. 
This will give all the room one desires, and through 
it one can feel almost the entire floor of the bladder 
and dig out the isolated tumors in the intravesical 
walls. It will not retard the recovery of the case, 
and does away with the necessity of tube drainage. 
(14) (a) Irregular rupture or tear of the 
bulbous urethra by the careless handling of the staff 
on the part of assistants. This was followed in one 
case by a fistula, which is not yet entirely closed 
after seven months. 

(b) Excessive primary hemorrhage. 1. Sec- 
ondary hemorrhage, requiring in one case supra- 
pubic cystotomy and followed by sloughing of the 
rectal wall from the very tight packing required of 
the perineal wound with gauze soaked in adrenaline 
chloride solution. 2. Rapid formation of calculous 
deposits upon the eschars where the urine was al- 
kaline, requiring intravesical or intraurethral 
curettage for their removal. 

(c) Sloughing of cellular tissues of abdominal 
wall and, once, separation of pubic symphyses. 

(A) In my hospital, dispensary and private 
practice during the past seventeen years I have 



PROSTATIC HYPERTROPHY. 81 

treated more than five hundred cases of men for 
chronic prostatic hypertrophy, and had watched 
most of them go helplessly to ground under the old 
palliative methods. Faulty as these old methods 
are, I am not yet ready to unconditionally abandon 
them. I have given what I regard as a fair trial 
to the sexual operations for the relief of this condi- 
tion in at least thirty-two cases, and have followed 
the experience of my colleagues in fully as many 
more. I see no reason for continuing to do them. 
I have used the Freudenberg-Bottini or the instru- 
ment of Hugh Young in twenty-nine cases. It has 
its limits of usefulness, but any general surgeon 
or urologist who seeks to give to his prostatic pa- 
tients the base care and best advice under all cir- 
cumstances cannot afford to ignore it x>r entertain 
foolish prejudice against it. His time will be well 
spent in learning how to use it. I have employed 
permanent supra-pubic drainage eight times for 
prostatic obstructions ; when other measures would 
be useless or inadvisable, it is a valuable resource. 
As a radical procedure, I have done twenty-one 
supra-pubic or combined prostatectomies, and will 
probably, unless my experience rises into hundreds 
of cases, never do so many again. I am, however, 
glad of the experience, for there are cases that can- 



82 PROSTATIC HYPERTROPHY. 

not be dealt with successfully by any other method. 
Out of the twenty-eight perineal prostatectomies I 
have done, I have met very few that I would call 
easy, and but one that did not give many uneasy 
moments. 

The general outcome of the prostatotomies and 
the prostatectomies have been good ; best of all has 
been that of perineal prostatectomy. But deaths 
occur, and the results are not always faultless, even 
in the most skillful hands. 



PROSTATIC HYPERTROPHY. 83 

CHARLES GHASSAIGNAC, M. D., 

Of New Orleans, La. 

(1) All else equal, sedentary pursuits seem to 
predispose, but it may be because those following 
them are apt to be more in the class of those who 
apply for relief. 

(2) The nervous, I believe. I have had more 
patients among the lean. May it not be in part 
because it is a disease of old age, and that the obese 
are less likely to live old? In other words, a co- 
incidence rather than a relation of cause and effect? 

(3) I am an agnostic on this point. 

(4) Comparatively small. It assists, but I rely 
more on rectal touch, measurement of prostatic ure- 
thra, resistance to metallic sound and manner of en- 
trance of same, etc., a swell as patient's history and 
symptoms. 

I have become accustomed to the Nitze cystoscope 
and generally use that. 

(5) I have had patients among total abstainers 
as often as among those who use a good deal of al- 
cohol, perhaps more. 

Constipation, in my opinion, is a result rather 
than a cause. 

(6) Briefly, in cases that have only intervals 



84 PROSTATIC HYPERTROPHY. 

of trouble or "attacks;" in cases accustomed to 
catheter life, who have learned aseptic precautions, 
and are very old ; in those whose general condition, 
especially as regards kidney troubles, would pre- 
clude safety in operation. 

(7) No. 

(8) Yes. Three. One death;* one improve- 
ment ; one unimproved. 

(9) Yes. Seventeen recorded cases; two re- 
cently operated upon and not yet discharged, 
celebral derangement. 

One death, apparently from septicemia and ure- 
mia. Kidneys were bad, bladder was infected; 
would now prefer supra-pubic drainage or even 
prostatectomy in such a case, though not promis- 
ing for any procedure. One unimproved except as 
to easy entrance of catheter. All others improved. 
Nine apparently perfectly well, of whom five yet 
under observation; one of the cases was in a man, 
eighty-five years old, who had had to use catheter 
with increasing frequency for many months, and 
had not voided urine without it for several weeks. 
He remained well for four years, up to the time of 
his death, at eighty-nine years of age, from senility 
and chronic diarrhoea. 

* Death was not immediate, and was preceded by cerebral derangement. 



PROSTATIC HYPERTROPHY. 85 

In one case had a urinary scrotal fistula from ex- 
cessive cauterization posteriorly; it healed in two 
weeks and patient made a good recovery. 

(10) Many times. Previously as a selected 
treatment, cases not recorded properly. Within 
last five years, only as an emergency operation in 
cases of retention with impossibility of catheteriza- 
tion. One last year, with numerous false passages 
caused by awkward attempts of catheterization and 
weak from loss of blood. Kecovered, and after 
closure of fistula was able to fairly empty bladder ; 
like result in several. 

(11) Twice. One recovery with good results. 
One death. 

( 12 ) Never yet, but am waiting for an oppor- 
tunity. Believe it is perhaps the best in compara- 
tively young and strong subjects, as not only they 
can stand it better, but, having longer to live, thor- 
oughness of removal is important. 

( 13 ) Bottini is yet my preference, chiefly owing 
to smaller mortality, and as I have had good results 
in the majority of cases. 

(14) Can recall only one; in a Bottini case, 
some extravasation of irrigating fluid, boracic solu- 
tion, subsequent to operation, due no doubt to ex- 
cessive length of posterior section; scrotum was 



PROSTATIC HYPERTROPHY. 






slightly incised for drainage and no harm resulted, 
as catheter was kept en demeure during healing. 

(A) Data not just at hand to arrange system- 
atically. 



PROSTATIC HYPERTROPHY. 87 

HENRY H. MORTON, M. D., 

Of Brooklyn, N. Y. 

(1) No answer. 

(2) No answer. 

(3) No answer. 

(4) The cystoscope I find very valuable in out- 
lining the size and shape of the intravesical 
growths. In several cases it was only possible to 
make a diagnosis of prostatic hypertrophy by its 
use, as rectal examination showed no enlargement 
at all. In each case, however, there was an enlarged 
middle lobe which acted as an obstruction and was 
plainly visible by the cystoscope. 

It is always desirable to exclude the presence of 
calculus, and this can be best accomplished by the 
cystoscope. 

The instrument which I use entirely for this pur- 
pose is the Nitze observation cystoscope. 

(5) No ansicer. 

( 6 ) The present hight rate of mortality in pros- 
tatic operations induces me to advise patients to 
use palliative measures so long as they can be made 
reasonably comfortable in that way. 

Palliative measures consist of regular catheteri- 
zation and bladder washing, and if there is much 
spasm of the cut-off muscle and irritability of the 



88 PROSTATIC HYPERTROPHY. 

post urethra, the passage of large sized sounds has 
seemed at times to be of use. 

(7) No answer. 

(8) No answer. 

(9) I can give only my general impressions of 
the Bottini operation, which I have done in perhaps 
a dozen cases. 

Its applicability seems to be limited to the small, 
hard, fibrous prostates, which form a distinct bar 
across the vesical outlet. Bottini's operation seems 
to me distinctly contra-indicated in the large ade- 
nomatous growths. 

With regard to the permanency of the relief I 
cannot state, as my cases all drifted out of sight 
(they were, with one exception, all hospital cases), 
with two exceptions. 

One of these, I understand, relapsed after the op- 
eration, and the other would have temporary at- 
tacks of retention from a swelling and closing up 
of the incisions made by the Bottini knife. 

The incisions were clearly visible, however, with 
the cystoscope a year after the operation. 

His prostate was subsequently removed by Dr. 
Alexander in Bellevue Hospital, and six months 
afterwards he reported to me that he had been free 
from trouble since the prostatectomy. 



PROSTATIC HYPERTROPHY. 89 

(10) No answer. 

(11) No answer. 

( 12 ) I have done prostatectomy five times. 

In three cases I made a snpra-pubic incision for 
the purpose of depressing the prostate, and enu- 
cleated the prostate through a perineal incision. 

In the other two cases I simply made the perineal 
incision and enucleated through that. 

The incision which I made in the perineum was 
the ordinary one for external urethrotomy, and I 
found that form of incision gave ample room for 
enucleating with the finger. The results were as 
follows : 

One death from shock forty-eight hours after the 
operation. 

One death from infection of the supra-pubic 
wound one week after operation. 

Three recoveries. 

( 13 ) I have no operation of choice. 

The operations which I consider at present are: 
Prostatectomy perineal, supra-pubic, or a combina- 
tion of both, and Bottini's operation. 

The choice of operation, I believe, depends entire- 
ly upon the 

a. Form of the enlargement, i. e., whether of the 
adenomatous or fibroid type. 



90 PROSTATIC HYPERTROPHY. 

b. The direction of growth, i. e., whether it is 
chiefly intra- vesical or towards the rectum, and, 

c. The age and general condition of the patient. 
I think that for me who are in fair health, even 

though they may be old, with large adenomatous 
prostates, perineal prostatectomy, without a supra- 
pubic incision, is a suitable operation. 

If the prostatic growth is chiefly intravesical, the 
supra-pubic operation may be required. 

If the growth is of the mixed type, i. e., adeno- 
matous and fibroid, and if the fibroid elements 
largely predominate, it may be necessary to make 
a supra-pubic opening in order to hold the prostate 
steadily while it is being enucleated from below. 

If a large vesical calculus is present, a supra- 
pubic incision may be demanded for its removal. 

A supra-pubic incision does not seem to be re- 
quired merely because the browth is of large size 
and extends high up towards the bladder, since it 
is not difficult to enucleate these prostates from 
below. 

With the above exceptions, my strong preference, 
based, to be sure, upon a limited number of cases, 
is for the perineal route withoujt supra-pubic in- 
cision and making only a longitudinal incision into 
the urethra, as in external urethrotomy. 

( 14 ) No answer. 

(A) No answer. 



PROSTATIC HYPERTROPHY. 91 

HOWARD LILIENTHAL. M. D., 

Of New York City. 

(1) Most of niy cases active indoor, but do not 
believe that any occupation can be shown to have 
caused the trouble, judging from my cases alone. 

(2) The lean and nervous, though some of my 
cases were obese and a number were phlegmatic. 

(3) Fibroma and fibromyoma within the cap- 
sule. 

(4) In my cases of very little service. The ob- 
servation cystoscope, with the prism within the 
angle so as to look around a corner, has been used. 

(5) But one of my patients used alcohol to ex- 
cess; nearly all drank very moderately. Constipa- 
tion not a marked factor. 

(6) In diabetics, careful catheterization with 
the administration of urinary antiseptics is advised, 
unless there is active and alarming hemorrhage, 
when supra-pubic cystotomy is advised. No pros- 
tatic operation. 

(7) In only one case, the patient being very 
weak. Death from urinary sepsis, which was al- 
ready present before result could be observed. Op- 
eration apparently did not hasten fatal outcome. 

(8) Three cases ; all with temporary relief only. 



92 PROSTATIC HYPERTROPHY. 

One remained well, but with some ounces of resid- 
ual urine, for about six months, when catheter cys- 
titis supervened. He was not in New York at the 
time, and I lost sight of him. One case developed 
ptyalism. ( Note connection between parotids and 
testes). 

(9) Never. 

(10) Temporary improvement. Have practiced 
it many times before the days of prostatectomy. 

(11) Thirteen times. One death, from uremia, 
within twenty-four hours, patient having been ure- 
mic at time of operation, which was an imperative 
one. All others were cured so that there was no 
residual urine. 

(12) Never, except partial in one case in which 
it became necessary to abandon perineal route and 
attack from above, because of large size of prostate. 

(13) Supra-pubic without perineal drainage; 
better exploration of bladder; obliteration of the 
trigonal pouch on healing. Traumatism to impor- 
tant structures less than by perineal. Quicker. My 
own very satisfactory results will probably induce 
me, in most cases, to continue as I have done in the 
past. 

(14) None during the operation. Suppurative 
epididymitis in one case after operation; non-sup- 



PROSTATIC HYPERTROPHY. 93 

purative epididymitis in one case after operation. 

(A) Operation takes from twelve to thirty 
minutes. Shock is very moderate; often absent. 
Severe post-operative hemorrhage in two cases, both 
recovering. Sexual power — i. e., potentia coeundi 
— retained in all of the younger and some of the 
older patients. 



94 PROSTATIC HYPERTROPHY. 



ALEXANDER HTJ&H FERGUSON. M. D., 
Of Chicago, III. 

(1) Nearly all my cases were robust and led 
active outdoor life, riding, etc., but soon lost flesh 
and became nervous. More were physicians than 
any other class. 

(2) Temperament plays no part. 

(3) Infection engrafted on hyperemia or trau- 
matism. In all my cases the tissue changes were 
inflammatory in character. 

(4) Can make diagnosis without cystoscope. It 
punishes a patient to use, and the majority of cases 
cannot stand it. The clinical history alone is suf- 
ficient on which to base a diagnosis in the vast ma- 
jority. The sound and finger are the instruments 
most used by me. 

(5) Constipation is 75 per cent. Alcoholism 
caused congestion and retention; exposure to cold 
was often followed by retention. 

(6) (a) Catheterization for retention. 

(&) Aspiration for retention if catheter cannot 
be passed. 

(c) Perineal section and drainage in desperate 
cases too bad for a radical operation. 



PROSTATIC HYPERTROPHY. 95 

(d) I have used bougieing to advantage, but it 
is dangerous. 

( e ) All these means are only palliative to pros- 
tatectomy. I do not practice palliation very much. 

(7) Yes. About twelve cases. All but two 
temporarily benefited. None cured. I have dis- 
carded the procedure. 

( 8 ) Yes. Three times. No benefit permanent- 
ly ; no result at all in two. 

( 9 ) Yes. Three times ; one death ( septic ) . No 
permanent relief. I know now that they were not 
suitable for Bottini. 

(10) Never practiced it. Have removed the 
prostate via perineum to cure supra-pubic fistulse. 

( 11 ) About twenty-four with six deaths. I 
have abandoned this operation. 

N. B. — Thought I had about fifty cases until J 
began to count them up. 

(12) Twenty-nine times; one death, the rest 
cured. The Y shape gives most room, but greatest 
traumatism. I find so much room unnecessary. 

(13) Median perineal, (a) It affords ample 
room. (5) The traumatism is minimized, (c) 
Drainage is perfect, (d) Never applied a ligature 
on a vessel. 

(14) Opened the peritoneal cavity in one case 



96 PROSTATIC HYPERTROPHY. 

between the rectum and bladder, with no ill result. 
Post-operative complications: (a) Epididymitis 
in five cases, mild in character, (b) Rectal fis- 
tulas in two cases, both caused by careless dressing 
over a week after the operation by the man in 
charge. One of these cured since by operation. The 
other has vesical control. 

(A) Supra-pubic prostatectomy, 25 per cent 
mortality. 

Perineal prostatectomy, 3.4 per cent mortality. 

Bottini prostatotomy, 33 1-3 per cent mortality. 

(One out of three). 



PROSTATIC HYPERTROPHY. 97 

EUGENE FULLER. M. D., 
Of New York City. 

(1) I do not feel convinced that any occupation 
in particular predisposes to prostatic senile hyper- 
trophy. Those who have led very active lives, as 
far as I can clinically observe, suffer about equally 
with those of sedentary habits. Neither do I think 
that an antecedent history of gonorrhcea can be 
reckoned as an etiological factor. We do not as 
yet know the etiology of this disease. 

(2) I do not think that any of the above enu- 
merated conditions exercise any causative effect. I 
have observed many clinical cases under each of 
these subdivisions. 

(3) I do not know further than that certain 
races seem to be exempt, as for instance Chinese 
and Japanese. I have seen one case, and only one, 
in a full-blooded negro. 

(4) The cystoscope in this connection is only 
of secondary importance. If there are projecting 
intravesical hypertrophies they can be seen 
through its employment. Digital feel per rectum 
and instrumental examinations per urethra of the 
prostatic portion of the canal by searcher and by 



98 PROSTATIC HYPERTROPHY. 

silk-woven catheter, constitute the usual instru- 
ment means of diagnosis. 

(5) I do not know that habit is responsible. 
Prostatic hypertrophy in many instances is of itself 
a sufficient cause for constipation. If one has pros- 
tatic obstruction, that obstruction may be increased 
by the taking of alcoholics. 

(6) I advise palliative as a poor substitute for 
radical treatment, chiefly in cases where the indi- 
viduals are so frightened at the suggestion of op- 
erative relief that I feel that there is no use discuss- 
ing the matter until, perhaps, the suffering due to 
the advancement of the disease has made the patient 
amenable to argument. Palliative treatment prac- 
tically consists of resort to the catheter. 

(7) No, but have watched results in the cases 
of others. Saw one case wherein some relief in 
symptoms resulted. 

(8) Yes, once. Patient died five weeks after of 
acute mania, prostatic obstructive symptoms per- 
sisting up to death. 

(9) No, I consider the operation unsurgical. It 
is more dangerous than prostatectomy at my hands ; 
it is uncertain in its results; many of the cases 
wherein cures have been claimed for it have re- 
lapsed after a year or so from the date of opera- 






PROSTATIC HYPERTROPHY. 99 

tion. In any event it is only applicable to a few 
selected cases out of many. 

( 10 ) Supra-pubic drainage, the prostatic condi- 
tion being left in "statu quo" I consider very inef- 
ficient and half-way surgery. When I open the 
bladder supra-pubically I always remove the pros- 
tatic obstruction except in case of cancer. 

(11) Considerably over 100 times my results 
are radical, permanent and excellent. My mortal- 
ity, formerly larger, has for the last year been below 
five per cent. 

(12) Somewhat under 100 times my results are 
radical, permanent and excellent. My mortality 
has for the last year by this operation been under 
five per cent. I use the median incision. 

( 13 ) I study each individual case and make my 
choice of operation depend on the condition of the 
vesical walls and on the size and extent and con- 
sistency of the prostatic hypertrophy. I choose 
perineal prostatectomy instead of supra-pubic, 
where nothing special exists to contraindicate that 
form of operation. 

(14) There are numerous complications to 
guard against in these old subjects. The more ac- 
customed the surgeon is to this form of surgery, 



100 PROSTATIC HYPERTROPHY. 






and the more alert he is, the fewer complications 
he will have in his practice. 

(A) In my book on "Diseases of the Genito- 
urinary System," and in the numerous articles I 
have written on the subject, one will be able, if de- 
sirous, of getting familiar with my ideas in the sub- 
ject. 



PROSTATIC HYPERTROPHY. 101 



JOSEPH BILTJS EASTMAN, M. D.. 
OJ Indianapolis, Ind. 

( 1 ) I have observed prostatic hypertrophy with 
about equal frequency in men of laborious, active, 
outdoor pursuits and those whose occupations are 
sedentary. I have, therefore, not formulated any 
opinion as to whether occupation should be regard- 
ed as an etiologic factor. 

(2) So far as my limited experience is con- 
cerned, the phlegmatic and obese. 

(3) In the course of microscopical studies of 
the prostate prosecuted for the purpose of deter- 
mining the origin of "corpora amylacea, ,? I have re- 
peatedly noted in glands only very slightly hyper- 
trophied the classical tissue changes of inflamma- 
tion as described by Green and Cienchanowski. I 
am of the opinion that inflammation bears an im- 
portant causative relation to prostatic hypertrophy. 

(4) The cystoscope is of slight value in the 
diagnosis of this particular condition. Complica- 
tions like calculus and cystitis may be more clearly 
defined, and with a lens instrument like the modi- 
fied Casper, a third lobe may under favorable con- 
ditions be imperfectly seen. 

(5) I have not been able to assure myself that 



102 PROSTATIC HYPERTROPHY. 

habitual indulgence in alcoholics predisposes to 
prostatic hypertrophy. No one of my cases con- 
cerned a hard drinker. Whether constipation bears 
a purely causative relation I do not know. 

(6) Palliation in no case unless operation can- 
not be borne because of extreme debility. Contin- 
uous or intermittent catheterization, bladder irri- 
gation, neutralization of the urine, stimulation and 
sedation, emptying of bladder in knee-chest posi- 
tion, application of silver nitrate to prostate per 
rectum, sounding, dieting, catharsis, diuresis, etc., 
pro re nata. 

(7) One case; negative result. 

(S) I have made five castrations for prostatic 
hypertrophy with slight temporary relief in two 
cases. One death from acute mania. 

(9) I have cauterized the prostatic collar 
through a perineal incision with the instruments 
and after the precepts of Dr. W. N. Wishard, with 
satisfactory results. Have secured excellent blad- 
der drainage by this method. 

(10) In one case; I am opposed to the practice 
of atempting to coax water to run up hill, unless for 
definite reasons perineal drainage or continuous 
catheterization cannot be employed. 



PROSTATIC HYPEETROPHY. 103 

(11) One case; pedunculated median lobe 
hypertrophy; good result. 

(12) Twice, with favorable results; the invert- 
ed Y incision. 

(13) Perineal prostatectomy; easier of execu- 
tion, better control of hemorrhage, better drainage. 

(14 Acute mania after castration. 

(A) My observation and work have impressed 
me with the importance of early operating in pros- 
tatic hypertrophy. Prostatic hypertrophy is a pure- 
ly surgical disease, and all or part of the prostate, 
according to the nature of the enlargement, should 
be removed before serious changes in bladder and 
kidneys appear as complications. 

If we may take the history of other surgical pro- 
cedures as our guide, we may with fairness assume 
that with education of the laity and the profession 
regarding the importance of early and thorough 
operating, the mortality from this disease may be 
steadily lowered. The operation selected must be 
one which will meet the exigencies of the peculiari- 
ties of the prostatic deformity and stage of the dis- 
ease in the individual case. 



104 PROSTATIC HYPERTROPHY. 

HILARY M. CHRISTIAN, M. D., 

Of Philadelphia, Pa. 

(1) I have never been able to see that occupa- 
tion had any bearing in producing hypertrophy of 
prostate. 

(2) I cannot say. 

( 3 ) I am inclined at present to believe that the 
overgrowth of normal glandular and muscular ele- 
ments of the prostate gland, constituting the hyper- 
trophy is first of all congestive, secondarily, inflam- 
matory in character. 

(4) The cystoscope is not necessary in making 
a diagnosis. It is useful in determining the extent 
of the growth into the bladder and the lobe most in- 
volved. Mtze or Albarran. 

(5) I do not think that either is responsible 
directly for prostatic hypertrophy, but each has a 
very bad effect upon the growth after it has devel- 
oped. 

(6) In nearly all cases. Catheter life, irriga- 
tion of bladder, internal administration of genito- 
urinary antiseptic drugs. Dilatation of prostatic 
urethra with Kollman. Prostatic dilator. 

( 7 ) Yes ; three times ; temporary relief only. 

(8) Yes; six times; good result in two cases; 



PROSTATIC HYPERTROPHY. 105 

fair result in one case; no improvement in three 
cases. 

(9) Yes; four times; permanent relief up to 
present time in three ; no complications. 

(10) Six cases of badly infected bladders with 
urinary fever; seemed to afford patients consider- 
able comfort; of course did not cure. 

( 11 ) Twice ; one apparent cure. 

(12) Have not performed the operation. 

(13) The Bottini in advanced cases with in- 
fected bladder and possibly kidneys, because it is 
safe. In younger subjects supra-pubic prostatec- 
tomy, because it is more thorough. 

(14) None. 

(A) I am a firm believer in the palliative treat- 
ment of the hypertrophied prostate. In cases with 
marked cystitis I am in the habit of using continu- 
our catheterization. ( See ad Therapeutic Gazette, 
February 15, 1901). I believe that 80 per cent, or 
even 90 per cent of cases can live comfortable lives 
with the use of aseptic catheterization. 



106 PROSTATIC HYPERTROPHY. 

ROBERT TTJTTLE MORRIS, M. D., 

Of New York City. 

(1) No definite testimony. 

(2) In my particular set of cases the men have 
belonged to the lean and nervous type chiefly. 

(3) Presumably a simple degenerative charge, 
similar to that which occurs in the uterus. 

(4) Of service in determining the nature of 
some of the complications that involve the bladder. 
I use the Kochester S. A. cystoscope at present. 

(5) I rather doubt if they have any bearing. 

(6) Palliative treatment for cases without seri- 
ous complications, and for cases with such serious 
complications that the comparative danger between 
operation and no operation is too great. Standard 
methods. 

(7) Yes, one case. No result of consequence. 

(8) No. 

(9) No. 

(10) Several cases in former years. Now pre- 
fer prostatectomy when feasible. 

( 11 ) Three cases. Combined operation ; satis- 
factory result. 

(12) Three cases; semilunar. All the patients 
benefited. 



PROSTATIC HYPERTROPHY. 107 

(13) Must depend upon the case. In cases re- 
quiring special drainage, combined operation. In 
others, the simple perineal operation. 

(14) None. 

(A) It has been chiefly palliative until recently. 



108 PROSTATIC HYPERTROPHY. 

B. MERRILL RICXETTS. M. D.. 

Of Cincinnati, Ohio. 

(1) Cause unknown. More frequent among 
civilized races. Occupation and sedentary habits 
are probably the greatest factors in its production. 

(2) Have not noticed any difference. 

(3) Don't know. 

( 4 ) A great aid where neoplasm is intravesical. 

( 5 ) Have no evidence that they are a cause, but 
believe them to be of more or less influence in its 
production. 

( 6 ) Inoperable cases ; those who could not with- 
stand prostatectomy. 

(7) Once. No benefit. 

(8) Twelve times. Double orchidectomy. Ex- 
cellent results in majority of cases. Cure in one 
seventy-three years old at end of five years. See 
"Cincinnati Lancet-Clinic," pages 396-688, 1902. 

( 9 ) Never approved of the cautery ; never did it. 

(10) Never did it. 

(11) Never made one. 

(12) Five times. Perfect drainage; later me- 
dian incision. 

(13) Perineal prostatectomy. 

(14) Nona 



PROSTATIC HYPERTROPHY. 109 

(A) Have made three prostatectomies, two 
complete, one partial. The two were emergencies 
in which vesico-rectal fistula was accomplished. Pa- 
tients utilize rectum for urinary receptacla See 
Lancet-Clinic, October 1, 1902, to February 14, 
1903. 



110 



PROSTATIC HYPERTROPHY. 



FERD O. VALENTINE. M. D., 

Of New York City. 

(1) Most of the patients with prostatic hyper- 
trophy whom I have treated were and are in seden- 
tary occupations. I would not, however, conclude 
herefrom, except in general way, that sedentary 
pursuits are essential factors in this condition. 

(2) I my experience the lean old men and the 
obese young men. 

(3) I have not formed an opinion on this ques- 
tion. 

(4) The cystoscope has been and is of invalu- 
able service to me, especially in the diagnosis of 
prostatism, where the enlargement bladderward is 
more marked than rectumward. 

I use the Mtze, Casper, Albarran and Kollmann 
cystoscopes ; often succeeding with one when I fail 
with another. 

(5) a, I do not know, except as answered to 
question No. 1. 

b. Alcohol and constipation, or either alone, cer- 
tainly aggravate the sufferings from prostatism. 

( 6 ) a. When the residual urine is aseptic and 
does not exceed 120 c. c. (fig. 3iv). 

b. Methodical, careful aseptic catheterism, as 



PROSTATIC HYPERTROPHY. Ill 

detailed in "Surgical Asepsis of the Urethra and 
Bladder" {Journal of the Am. Med. Assn., January 
12,1901). 

(7) Yes. Eight. None. 

(8) No. 

(9) I have not performed the Bottini incision 
for fear of operating in the dark. 

( 10 ) I turn over all capital operations to oper- 
ators. 

(11) No answer. 

(12) No answer. 

(13) No answer. 

(14) No answer. 

(A) Deeming with Guyon that prostatism is 
"an infirmity, not a disease" while the patient can 
be kept comfortable and free from danger, my pros- 
tatic work has been and is palliative. I have no 
reason to regret this or to change from the conser- 
vative methods. 



112 PROSTATIC HYPERTROPHY. 

EDMUND ANDREWS, M. D., 

Of Chicago, III. 

(1) I have not observed any effect of occupa- 
tion. 

(2) I have not been able to observe any differ- 
ence except that long and severe suffering seems to 
promote leanness. 

(3) It is only conjectural. It seems to me that 
vigorous men are the most frequent victims, but I 
have no scientific proof that sexual excess is an 
actual cause. 

( 4 ) The cystoscope is of some value, but not ab- 
solutely necessary. I am not certain which instru- 
ment is best. 

(5) The relations of alcoholism as a cause are 
established. Total abstainers are not exempt, and 
I have not observed that constipated men are spe- 
cially liable. 

(6) When the patient can preserve his health 
and comfort by the velvet eye catheter and boric 
acid injections, I advise not to operate. 

(7) Have ligated the vasa deferentia in a few 
cases only. Some are greatly benefited, but not all. 

( 8 ) I have castrated a few cases. Most of them 
were benefited and relieved of pain, but some of 



PROSTATIC HYPERTROPHY. 113 

them still had to continue the catheter. Those ex- 
amined years later showed that the prostate had be- 
come completely atrophied, and yet some of them 
still required the catheter. 

(9) I have observed the Bottini but not prac- 
ticed it. Some are permanently cured or benefited ; 
some remain unrelieved; some few had permanent 
incontinence after it. 

(10) Only for temporary purposes. For per- 
manent purposes I prefer other operations. 

(11) Have not tried it. 

( 12 ) Have not personally tried it. 

(13) This question is not yet fully settled. At 
present my preferences incline in the following or- 
der: 

(a) Bottini' s operation. 

(b) Prof. E. Wyllys Andrews' infra-pubic op- 
eration, which I value very highly. 

(c) Perineal operation. 

(d) Supra-pubic operation in a few cases only. 
Bottini's operation is safest (except vasectomy). 
E. Wyllys Andrews' operation takes away only the 
front of the prostate. I think it is next to Bottini's 
in point of safety and more efficient. Total perineal 
prostatectomy is the most dangerous of the three. 
Total supra-pubic prostatectomy is dangerous. 

(14) Cannot sufficiently recollect my cases. 
(A) No answer. 



114 



PROSTATIC HYPERTROPHY. 



WALTER G. SPENCER. F. R. O. S.. M. S.. M. B. f 

Of London, England. 

(i) mi. 

(2) Nil 

(3) Nil 

(4) Useful as an aid or in confirmation. 

(5) No answer. 

(6) No answer. 

(7) No answer. 

(8) No answer. 

(9) No answer. 

( 10 ) Many times. Poor, on account of nervous 
troubles. 

(11) Often. Very good. 

( 12 ) Many times with very satisfactory results. 

(13) (a) Supra-pubic for large, soft, mobile, 
with dilated bladder. 

( o ) Perineal for hard, fixed with small bladder, 
also "collar-like" obstruction. 

( 14 ) Complications, because case too late. Gen- 
eral and kidney troubles. 

(A) I have never done vasectomy or castration. 

Prostatectomy has the advantage of being a radi- 
cal method when the patient is relatively young and 
strong enough. If successful the patient may re- 



PROSTATIC HYPERTROPHY. 115 

turn to his occupation, and especially among the 
poor there are great difficulties in carrying out 
treatment depending upon catheterism or involv- 
ing continuous medical attendance, and many pa- 
tients, therefore, become paupers. 

Supra-pubic prostatectomy is best done when 
there is a large bladder and a pedunculated middle 
lobe. A contracted bladder and a post-prostatic 
pouch with enlargement of the lateral lobes are not 
so favorable conditions. I have operated by the 
supra-pubic method when the bladder was con- 
tracted with the prostatic obstruction mainly like 
a collar, and although the patient did well, yet the 
operation was difficult, no good view could be ob- 
tained, and, therefore, recurrent hemorrhage might 
well have taken place. As regards other ways of 
performing perineal prostatectomy, there is not 
such good exposure of the prostate, and the cauteri- 
zation by Bottini's and other methods is done in the 
dark, which, if the cautery is too hot, may lead to 
hemorrhage and sloughing. If performed as de- 
scribed there is no danger of a perineal fistula, al- 
though this would be a trivial matter as compared 
with a supra-pubic one. Castration and vasectomy 
appear to be very uncertain in their results, and 
leave a post-prostatic pouch undrained, with pos- 



116 PROSTATIC HYPERTROPHY. 

sibly a calculus in it, so that renal complications 
progress. 

Conclusion, — The cases quoted indicate that this 
operation is especially applicable to certain in- 
stances of complicated structure, bladder calculi, 
and prostatic obstruction. The unsuccessful cases 
have shown too advanced disease of the kidneys. 
When this complication had not set in the results 
were good. 



PROSTATIC HYPERTROPHY. 117 



ROBERT HOLMES GREENE. M. D., 

Of New York City. 

( 1 ) Sedentary pursuits cause congestion and in- 
creased discomfort from an hypertrophied pros- 
tate. 

(2) The extent, character and nature of the dis- 
ease modify the suffering more than the tempera- 
ment. Other things being equal, the nervous. 

(3) It is the result of chronic inflammation, 
causing the formation of connective tissue which 
plugs up the mouths of the acini, causing them to 
dilate (pseudo adenoma) ; or the increase in the 
connective tissue takes place between the acini, 
causing atrophy of the prostate by compressing 
them, or if considerable in quantity causing a 
fibrous prostate. It generally commences as a 
chronic posterior urethritis from whatever cause. 
(See "Nature of Prostatic Hypertrophy," Greene 
and Brooks. — Journal American Med. Asso., April 
26, 1902). 

(4) Great service, not necessarily for diagnosis 
but. for prognosis as well, showing condition of 
bladder walls. Prostatectomy of any kind cannot 
be expected to completely cure when bladder walls 
much changed in character. 



118 PROSTATIC HYPERTROPHY. 

(5) Alcohol and constipation increase urgency 
of symptoms by causing congestion. 

( 6 ) Stimulate reaction by tonics. Irrigation of 
weak solutions of silver nitrate, etc., when it causes 
little trouble. Take on catheter life if necessary. 

(7) No. 

(8) No. 

(9) No. 

(10) Danger of infection of supra-pubic wound 
and difficulty of proper drainage. 

(11) No. 

( 12 ) Whenever I have had the opportunity, if I 
could conscientiously advise it. 

( 13 ) Operation as reported by Dr. J. P. Bryson 
of St. Louis, Annals of Surgery, 1902. 

(14) Possibility of urethro-rectal fistula. Of 
losing a piece of the prostate in bladder, and of 
causing impotence. 

(A) Given above. 



PROSTATIC HYPERTROPHY. 119 

WILLIAM N. WISHARD, M. D., 

Of Indianapolis, Ind. 

(1) I have observed no influence tending to 
produce hypertrophy from this cause. 

(2) I have noticed no difference. 

(3) I do not know. 

(4) Yes. Occasionally an instrument with a 
lens system aids in defining intra-vesical growths, 
but a direct view obtained with an air dilation cyst- 
oscope in inspecting small growths about the vesicai 
orifice is sometimes better. 

(5) I do not think alcohol has anything to do 
with it, but constipation may. 

(6) I advise palliative treatment when the 
symptoms are mild, and when for any reason an 
operation is inadvisable or declined by the {>atient, 

(7) No. 

(8) No. 

( 9 ) Yes, I have through an instrument especial- 
ly devised for the purpose and which I used through 
a perineal opening (see Journal Cutaneous and 
Genito-Urinary Diseases, June, 1902). Have also 
used a cautery through an air-dilated cystoscope. I 
use an extra long cautery introduced directly 
through the cystoscope. In one case now under ob- 



120 PROSTATIC HYPERTROPHY. 

servation the patient was almost wholly dependent 
on the catheter and had some growth near the vesi- 
cal orifice on the posterior wall of the urethra and 
had been cauterized three times at intervals of 
about two weeks. The patient is now able to empty 
all but one ounce of urine, and sometimes less has 
been found with the catheter, after voluntary ef- 
forts at urination. Five cases where the cautery 
has been used through a perineal opening with my 
instrument within the past two years still remain 
apparently well. The cautery was used through a 
perineal tube in some cases published by the writer 
in the Journal of Cutaneous and Genito-Urinary 
Diseases in March, 1892. A small tube was em- 
ployed and reflected light from a head mirror used. 
The results were apparently permanent and satis- 
factory, but no attempt was made to incise large 
growths. 

(10) Perhaps one-half dozen times, but I do not 
regard simple drainage by this method as of very 
great value. 

(11) Perhaps twenty-five or thirty times. The 
results have been more satisfactory when this 
method has been accompanied by a perineal incis- 
ion, i 



PROSTATIC HYPERTROPHY. 121 

(12) Probably sixty-five or seventy times. I 
have used a median perineal incision. 

(13) I have no operation of special choice but 
try as far as possible to determine what method 
best suits the individual case. 

(14) I have no especial complications except- 
ing occasional hemorrhage. 

(A) No answer. 



122 PROSTATIC HYPERTROPHY. 



A. E. HALSTEAD, M. D., 

Of Chicago, III. 

(1) My experience tends to show that indoor 
pursuits seem to favor prostatic hypertrophy. , 

(2) My cases have been nearly equally divided 
between fat and thin individuals. I have no data 
as to influence of temperament. 

(3) I can formulate no rule regarding the eti- 
ology. In a few comparatively young men in whom 
I have seen hypertrophy, I have reason to believe 
that chronic prostatitis was of etiologic moment. 
I do not believe that venereal excess nor venereal 
disease as a rule have much influence in producing 
this condition. The etiology, I consider, is that 
of new growths, the cause of which is yet unknown 

(4) None. 

(5) I believe constipation and rectal diseases, 
particularly hemorrhoids, may have some etiologic 
significance. Alcohol cannot be considered. 

(6) Only when patient is progressing favor- 
ably ; that is, when catheterization is successful and 
there is no great distress nor cystitis resulting from 
the catheter life. 

(7) I have divided the vas (vasectomy) in two 
cases without any appreciable results. 



PROSTATIC HYPERTROPHY. 123 

(8) I have performed orchidectomy in four 
cases. One recovered ; was well for six months, lost 
sight of after that. One died from ether nephritis. 
Two were improved — one considerably, and one 
slightly. 

(9) No answer. 

(10) I have operated a number of times, when 
I made a supra-pubic fistula. The exact number of 
cases I do not know ; probably ten ( 10 ) at least. I 
believe the operation has a distinct place in surgery, 
particularly in cases where prostatectomy is regard- 
ed as being contraindicated because of the low con- 
dition of the patient. 

( 11 ) I have operated by the supra-pubic route 
alone but once. I do not consider it a good oper- 
ation. In my case it simply resulted in a supra- 
pubic fistula, which relieved the patient for about 
one and one-half years, when he died. 

( 12 ) I have done four perineal prostatectomies. 
In one I did a combined supra-pubic and perineal 
because of the size and position of the tumor. A 
curved transverse incision has been my choice. 

( 13 ) The perineal, with a curved invision above 
the anus. Where the prostate is high, and if the 
tumor was very large and projected well into the 
bladder, I would make a supra-pubic opening to 



124 PROSTATIC HYPERTROPHY. 

facilitate its removal through the perineal incis- 
ion. 

(14) The only complication that I have en- 
countered in the operation was having a large pros- 
tate slip into the bladder, and with difficulty re- 
moved after it had been freed from its attach- 
ments. 

(A) (a) Vasectomy two cases; no improve- 
ment. 

( b ) Orchidectomy four cases ; one well for six 
months; one death from operation; two improved, 
one considerably, one slightly. 

(c) Bottini operations two; evacuation free 
after operation ; in one improvement in cystitis ; in 
one cystitis probably increased, no improvement, 
at least ; first operated one year, second about nine 
months ; in both general health improved. 

(d) Five prostatectomies, three perineal, one 
combined, one supra-pubic. Thee perineals all liv- 
ing, one six months, one four months and one three 
months after operation ; all greatly improved in gen- 
eral health; bladder condition in all greatly im- 
proved. One combined, two years after operation, 
has no supra-pubic fistula, and can be considered 
cured. The one supra-pubic operation lived one 
and one-half years, and with supra-pubic fistula; 
died of infection of the kidneys. 



PROSTATIC HYPERTROPHY. 125 



STUART McGUIRE. M. D., 

Of Richmond, Va. 

( 1 ) I have observed no difference with regard to 
occupation of patients with prostatic hypertrophy. 
Cases come to me as frequently from the farm as 
from the counting house. 

(2) I have observed no difference with regard 
to recurrence of the disease in the phlegmatic or the 
nervous, the lean or the obese. 

(3) I have no theory or explanation of the eti- 
ology of the disease. Lydston's theory of 
sexual overstrain is controverted by the fact 
that the disease is rarely if ever seen in the negro. 
Guyon's explanation of the changed relation of the 
base of the bladder to the vesical neck is more logi- 
cal. All that can be said at this time is that pros- 
tatic enlargement is an attendant of old age. 

(4) The cystoscope has been of little service to 
me in diagnosis. I rely almost entirely upon in- 
formation derived from the finger inserted in the 
rectum and a sound inserted in the bladder. 

(5) I have never seen the use of alcohol or a 
constipated habit act as a causative factor in pros- 
tatic enlargement, although they aggravate the con- 
dition when it exists. 



126 PROSTATIC HYPERTROPHY. 

(6) I advise palliation in all cases until symp- 
toms are unbearable, treatment consisting in regu- 
lation of the habits of life, the use of the catheter, 
irrigation of the bladder and the administration of 
urinary antiseptics. 

(7) No. 

(8) No. 

(9) No. 

( 10 ) Yes, in over ninety cases. Results are in- 
definite prolongation of life, cure of cystitis, relief 
of pain, but discomfort from unavoidable leakage 
from the supra-pubic artificial urethra. 

(11) No. 

(12) No. 

( 13 ) I have not yet decided which of the several 
operations proposed is best. I believe that pros- 
tatic surgery is in a stage of evolution and propose 
to wait and let other men make experiments and 
then profit by their results. 

(14) None. 
(A) No answer. 



PROSTATIC HYPERTROPHY. 127 

N. PENDLETON DANDRIDOE. M. D.. 

Of Cincinnati, Ohio. 

(1) The etiology of hypertrophy is, I consider, 
entirely unknown. I cannot trace any connection 
to any habits of life. 

(2) The condition of body or elements of char- 
acter have no influence. 

(3) Quien sabe — who knows. 

(4) Personally it has been of no use. The harm 
it has done probably fully balances the occasional 
good. 

( 5 ) Have not been able to trace any connection. 

( 6 ) The rule should be proper hygiene with the 
use of the catheter when it becomes needed under 
the strictest aseptic conditions. 

(7) No. 

( 8 ) Have castrated two cases with no benefit. 

(9) No. 

(10) Supra-pubic drainage is inferior to 
perineal drainage. 

( 11 ) Never. 

(12) Once complete with complete success; in- 
cision, inverted Y. 

( 13 ) Perineal — for drainage and prostatectomy 

(14) No answer. 
(A) No answer. 



128* PROSTATIC HYPERTROPHY. 

ALBERT J. OCESNER, M. D., 
Of Chicago, III. 

(1) I have not been able to find any cause in 
the occupation of patients. 

(2) In my experience the obese. 

(3) Age, recurrent infections, constipation, 
habitual neglect in evacuating the bladder, habitual 
sexual excess for a long period, seem the most usual 
corresponding points in the histories. 

( 4 ) I have not used it in these cases. 

( 5 ) I could not determine any relation between 
the use of alcohol and hypertrophy of the prostate, 
but almost all of these patients have been habitually 
constipated. 

(6) In cases suffering from acute infections, 
and in those suffering from advanced nephritis. 
Rest, a great abundance of pure, preferably dis- 
tilled, water, and taken at regular intervals, not at 
meal time. Lavage of bladder night and morning, 
with mild antiseptic. Uriseptin, 3j, in o ss hot 
water four times a day. 

(7) Yes, eight cases; three cured, three im- 
proved, two not improved. 

(8) Yes, seven cases; four cured, one improved, 
two died. 



PROSTATIC HYPERTROPHY. 129 

(9) No. 

( 10 ) I have made this operation many times in 
cases in which both stone of the bladder and hyper- 
trophy of the prostate were present, but eight times 
in cases of hypertrophy alone. Results: Cured, 
three; improved, four; died, one. 

(11) Cannot determine number, but results 
were so unsatisfactory that I abandoned the method 
some years ago. 

(12) Twice the combined supra-pubic and pe- 
rineal with one death ; nineteen times the perineal 
with one death and eighteen recoveries. 

I prefer the Zucker-Kandl incision — horseshoe — , 
with convexity upwards from os pubis to os pubis. 

(13) The perineal prostatectomy through the 
Zucker-Kandl incision, because the gland is perfect- 
ly exposed to view, the hemorrhage can be com- 
pletely controlled so that almost no blood is lost. 
The operation has a very small mortality. 

(14) Laceration of the anterior wall of rectum 
one case during operation. Slight hemorrhage 
after operation. Urinary fistula persisting for sev- 
eraL months in two cases. 

(A) Surgery of the prostate was extremely un- 
satisfactory until the simple perineal operation 
was introduced. I adopted this method fifteen 



130 PROSTATIC HYPERTROPHY. 

months ago after seeing it demonstrated by Dr. J. 
B. Murphy and Dr. A. H. Ferguson, and have used 
it in nineteen cases since then with very great satis- 
faction and benefit. 



PROSTATIC HYPERTROPHY. 131 



GEORGE O. MAC DONALD, M. D., 
Of San Francisco, Cal. 

(1) My experience leads me to believe that sed- 
entary occupations favor prostatic hypertrophy. 

(2) Phlegmatic and lean. 

N. B. — Probably their leanness is induced by the 
toxaemia. 

(3) Alcohol, gonorrhoea! cystitis and inflamma- 
tion of prostate in middle life, the prostate never 
having properly recovered ; or any condition which 
causes congestion of the vesico-prostatic plexus of 
veins, as excessive masturbation, toying with fe- 
males without proper emission, and liver conditions 
which cause the hemorrhoidal veins to become vari- 
cosed. 

N. B. — All this depends on how the hemorrhoid 
plexus is formed ; if the connection via the middle 
and inferior hemorrhoidal veins with the internal 
iliac is free, or if the blood is carried back from the 
plexus mainly by the superior hemorrhoidal and 
thus the portal system; the arrangement varies in 
different individuals. 

( 4 ) I do not consider the cystoscope to be of any 
material service. Any cystoscope that carries the 



132 PROSTATIC HYPERTROPHY. 

light at the distal extremity (bladder) and the blad- 
der inflated with air. 

(5) Alcohol, overfeeding, constipation and he- 
patic congestion are factors in hypertrophy. 

( 6 ) This is a hard question to answer. The con- 
dition of the patient, his arteries, heart, lungs, kid- 
neys, age, and the size and consistency of the pros- 
tate are all factors which must be left to the judg- 
ment and experience of the surgeon. 

It consists in simply keeping bladder clean, reg- 
ular habits, diet and catheterization by soft rubber 
instrument surgically clean. When drawing off 
urine have patient on knees and hands, being most 
particular that the end of the catheter is pushed 
close so no air enters bladder. 

(7) Have never done this operation, consider- 
ing it useless. 

(8) Same as answer No. 7. 

( 9 ) Have never used this procedure. Consider 
it unsurgical. 

(10) Do not do this. 

(11) Ten times. Four deaths; exhaustion due 
to shock and hemorrhage. Six living cases eminent- 
ly satisfactory. 

( 12 ) Once ; fatal. Favor the semi-circular. 

(13) Decidedly supra-pubic, because it is less 



PROSTATIC HYPERTROPHY. 133 

dangerous, quick, sure, and all the gland is removed 
in one or two pieces. 

(14) Supra-pubic; contracted and hypertro- 
phied bladder, considerable hemorrhage from the 
prostatic plexus of veins, shock, anuria and con- 
tinuous hemorrhage of a passive character. 

(A) Palliative treatment is generally unsatis- 
factory, insomuch as sooner or later infection ap- 
pears, with the usual kidney complications; it is 
very hard to make a patient understand the impor- 
tance of keeping to the instructions and living in 
surgical righteousness. The kind of instrument, 
which should always be soft rubber, and the diffi- 
culty sometimes experienced in getting even this in 
when the gland becomes congested, as it often does 
from many and various causes, is extreme. The 
position on the hands and knees, so as to draw the 
paunch behind the prostate. Uncertainty that the 
lubricant used is aseptic, soft and non-irritating, 
so that the treatment as a rule ends up disastrous- 
ly, and should not be followed if there be any 
chance of a successful surgical interference. 

The supra-pubic, in my opinion, is the only one 
to be followed, that is in the majority of cases. The 
chief feature in the operation is to suture the blad- 
der to the fascia and skin by an interrupted catgut 



134 PROSTATIC HYPERTROPHY. 

stitch, so that the viscus is well held up to the ab- 
dominal wall, there is very little trouble in shelling 
out the gland, and we are not working in the dark 
(notwithstanding Mayo Eobson to the contrary). 
I have never had any trouble in getting the abdom- 
inal wound to close within twenty-one days. Very 
often in the perineal method the whole of the gland 
is not removed, or only in pieces, at other times it 
is loose in its capsule; in such conditions the peri- 
neal makes the better operation so far as the length 
of the convalescence is concerned, but if the gland 
is not very large (and it need not be to cause a 
great deal of trouble), hard and very adherent to 
its capsule, then there is danger to sliping into the 
rectum with the finger just in front of the pros- 
tatic urethra, especially if the rectum be thin and 
atrophic, as it often is in thin old men. Hemor- 
rhage in the supra-pubic operation can usually be 
controlled by packing, and, in obstinate cases, 
using gauze wetted with a saturated solution of 
alum in the wound, the balance being sterilized 
gauze. 

Although I have done a great many perineal sec- 
tions for various bladder and urethral conditions, 
the only one I attempted for the removal of the 
prostate proved fatal, for the reason I punctured 



PROSTATIC HYPERTROPHY. 135 

the rectum by my finger. It was a prostate that 
would not readily shell. I had to use my cutting 
forceps (which I had made on my own pattern, 
and found out afterwards another man had been 
ahead of me), while trying to free some of the ad- 
herent gland the tip of my forefinger slipped. Then, 
of course, I had to lay the whole business open, 
sphincter and all. The patient lived about ten 
days, but gradually sank. My four deaths follow- 
ing the supra-pubic operation were from exhaus- 
tion, caused by loss of blood due to degenerated 
vessels, and because I did not give them sufficient 
individual care. A surgeon who removes a pros- 
tate must rely on no one until all danger is passed. 
In perineal incisions there is danger of injuring 
the rectum while shelling out the prostate, especial- 
ly if the rectum be atrophic and the anal sphincters 
well marked. If the rectum is ruptured, it is, of 
course, fatal in old and debilitated men. 



136 PROSTATIC HYPERTROPHY. 



W. FRANK GLENN, M. D., 

Of Nashville, Tenn. 

(1) I have never observed closely, but upon re- 
flection I find all of my patients have led active 
lives. 

(2) I have noticed no difference as to tempera- 
ment or flesh. 

(3) It is unknown to me, but I believe mastur- 
bation in youth, and excessive sexual indulgence in 
later years, to be the chief cause. 

(4) I do not get much aid from cystoscopy I 
like the Bransford Lewis instrument. 

( 5 ) I believe habitual use of alcohol and consti- 
pation have an influence, but sexual excess to be the 
chief cause. 

(6) The cases that are well, except for inability 
to completely empty the bladder, I usually advise 
regular use of catheter and washing out bladder. 

(7) Never did it. 

(8) Once, in a man eighty -two years old. He 
died. 

( 9 ) Never made it. Always perform prostatect- 
omy. 

( 10 ) Never used it. Prefer perineal. 

( 11 ) Never. 



PROSTATIC HYPERTROPHY. 137 

(12) Seven times ; two deaths, one from a heart 
complication ten days after operation, the other 
septic peritonitis four days afterwards; others re- 
covered. 

(13) Perineal prostatectomy. Drainage better. 

(14) None. Septic peritonitis and stenosis 
mitral valve. 

(A) In the large majority of cases the result 
has been all that could be desired, the patients 
afterward completely emptying bladder normally. 



138 PROSTATIC HYPERTROPHY. 

J. HENRY DOWD. M. D. 

Of Buffalo, N. Y. 

(1) Excepting those sedentary inclined, pur- 
suits (indoor or outdoor) have but very little bear- 
ing upon hypertrophy of the prostate. In my ex- 
perience, men living under either condition have 
been equal sufferers. 

(2) The large majority of cases occur in the 
obese, especially where there has always been men- 
tal activity. 

(3) The first seed of prostatic hypertrophy is 
shown in youth, developing insidiously as different 
causes arise, until a true pathologic condition is 
reached : 

Youth. — Ungratified sexual desire, masturbation, 
onanism. 

Adult — Abuse of the sexual appetite, follicular 
prostatis, gonorrheal in nature, stricture, unnatur- 
al sexual life and trying to accomplish impossibili- 
ties. 

(4) Regarding the lateral lobes, the finger is 
far superior to any cystoscope as a diagnostic 
agent. This instrument may be of value where 
there is involvement of the middle lobe. 

(5) A sedentary life tends towards hypertro- 



PROSTATIC HYPERTROPHY. 139 

phy. Alcohol is important as a predisposing 
cause. Constipation must be considered a very im- 
portant factor; it tends to continue, if not aggra- 
vate, the already congested or inflammatory condi- 
tion. 

(6) Palliation should be practiced in all cases 
where no relief, even of a temporary character, can 
be obtained from radical measures. Excepting in 
cases where the bladder may be looked upon almost 
as a suppurating cavity, this viscus plays but little 
part as a contraindicating agent against radical 
measures. On the other hand, damaged kidneys, 
even trivial in nature, but which have existed for 
a long time, offer a serious barrier to even a tem- 
porary alleviation of the symptoms. Palliative 
procedures depend entirely upon the existing con- 
dition; in some supra-pubic, in other perineal 
drainage should be the operation of choice. 

(7) I have tied and taken sections from the 
vas several times, but in only one was there much 
relief, and this temporary. It is my opinion that 
ligature or section of the vas deferens for hyper- 
trophy of the prostate gland is of value, and should 
be used in cases where there still remains sexual 
activity. Such was the case where temporary im- 
provement resulted. 



140 PROSTATIC HYPERTROPHY. 

(8) In a few cases of castration the result was 
practically nil. When any improvement has re- 
sulted, the condition was similar to that described 
in No. 7. 

(9) Never performed Bottini's operation. 

(10) Supra-pubic drainage should be con- 
sidered a procedure of last resort and only pallia- 
tive. There is no doubt it gives relief from the 
urgent urinary symptoms, but it is always followed 
by aggravated bladder complications which make 
life almost as miserable as when the urine was 
coming from below. One patient lived two years, 
and for awhile was in fair shape, but soon the blad- 
der became contracted, stone formed and morphine 
as a regular diet had to be resorted to. In my cases 
I am not proud of the results that followed this 
operation. 

(11) I have removed the prostate supra-pubic- 
ally but once, the patient dying in four days. 

(12) Have never removed the gland from be- 
low. From repeated operations for stone, abscess, 
etc., I am convinced that the inverted "Y" incision 
affords the greatest amount of room. In using this 
incision the rectum can be dissected backwards for 
an inch or so, thus bringing the gland clearly into 
the field. 



PROSTATIC HYPERTROPHY. 141 

( 13 ) There is no doubt but that the prostate at- 
tacked in the way described above can be removed 
much easier than by any other method. Using the 
inverted "Y" incision, with slight turning back- 
wards of the rectum, transfers the cutting and dis- 
secting process from darkness to light. 

(14) Hemorrhage is occasionally a distressing 
complication. Even in the hands of the most ex- 
perienced, tearing or almost complete destruction 
of the posterior urethra may complicate matters. 
The rectum has been lacerated, thus handicapping 
the reparative process. Uremia is the most serious 
drawback during post-operative conduct of these 
cases. 

Second. — Hypostatic congestion of the different 
important organs, as the kidneys or lungs, due to 
the recumbent position at an age when the blood 
vessels have more or less lost their tone. 

(A) Prostatectomy is still in its infancy. High 
mortality can only be lowered by attacking the 
gland early and before the upper urinary struct- 
ures have taken on pathological changes. 



142 PROSTATIC HYPERTROPHY. 

CHARLES H. MAYO, M. D.. 

Of Rochester, Minn. 

( 1 ) I have noticed but little difference. 

(2) The nervous and lean. 

(3) No answer. 

(4) It has been useful in differential diagnosis 
of prostatic bar and median lobe hypertrophy ; also 
in finding a small stone, once, and an ulcer of the 
base of the bladder, the real cause of the discom- 
fort. 

(5) While probably not responsible for the 
hypertrophy, they act later as a cause of acute ob- 
struction. 

(6) In patients with other physical infirmities 
which are more severe than the prostatic trouble. 
In extreme debility. In severe cystitis with de- 
bility. Best, tonics, bladder irrigation or tempo- 
rary supra-pubic drainage to cleanse the bladder 
and induce tolerance for interference. 

(7) Once. Partial relief. 

( 8 ) Six times, some with partial, others com- 
plete, relief. Most of these cases relapsed within 
two years. 

(9) No. 

( 10 ) Forty-three times. Improved condition in 



PROSTATIC HYPERTROPHY. 143 

all. Many relapsed, some remained improved, not 
well. 

(11) Thirteen supra-pubic prostatectomies. 
Good result in twelve. Two combined supra-pubic 
and perineal with success in one. 

(12) Ten perineal prostatectomies. Good suc- 
cess in nine. Inverted incision gives most room. 
Straight median is usually sufficient. 

( 13 ) At present supra-pubic for pendunculated 
middle lobe. Perineal for most cases. 

(14) Found enlarged prostate to be sarcoma, 
very bloody. General and kidney failure. 

(A). No answer. 



144 PROSTATIC HYPERTROPHY. 

WILLIAM K. OTIS, M. D. 

Of New York City. 

(1) As far as I am aware occupation has no ef- 
fect in the production of prostatic hypertrophy. 

(2) It occurs without reference to these condi- 
tions. 

(3) I do not know. 

(4) The cystoscope is of considerable value in 
the diagnosis, in showing the amount of internal 
overgrowth present. The "retrospective" cysto- 
scope, made from me by Wappler & Co., gives a 
good view of the internal urethral orifice which 
is of great service when prostatic hypertrophy is 
present. The same is accomplished by Prof. 
Young's cystoscope for this purpose. The ordinary 
cystoscope is of much less value. 

(5) Not responsible at all. 

( 6 ) Prevention of urinary infection, use of cath- 
eter, avoidance of exposure to cold and wet, care 
of general health — avoidance of constipation — uro- 
tropin. 

(7) Three cases without result. 

(8) One case; patient died two months after 
operation without improvement. 

(9) I do not approve of the Bottini operation. 



PROSTATIC HYPERTROPHY. 145 

Consider it dangerous in comparison with results 
obtained, and have never performed it. 

(10) Four cases; this being only a palliative 
operation the annoyance of the supra-pubic wound, 
irritation of the skin and odor are always present 
though the patient may be comparatively comfort- 
able otherwise. 

(11) No answer. 

(12) No answer. 

(13) The perineal operation with supra-pubic 
opening down to but not opening the bladder. The 
enucleation taking place through the perineal open- 
ing, the prostate being pushed down with the hand 
in the supra-pubic wound. Gives better drainage 
and quicker recovery than any other method. Most 
serviceable on thin subjects. 

(14) No answer. 
(A) No answer. 



146 PROSTATIC HYPERTROPHY. 

EDWARD MARTIN, M. D.. 

Of Philadelphia, Pa. 

(1) To no extent. 

(2) Obese, but it often makes them lean. 

(3) Probably chronic tubercular prostatitis. 
But I don't know. 

(4) Very little. Leiter Nitze. 

(5) None. 

(6) Frequency with residium, with or without 
infection. Symptoms non-crippling, non-progres- 
sive; purely local. Forced dilatation of interval 
vesical sphincter under nitrous oxide ; intermittent 
catheterization. 

(7) Yes. Four. Cure, one; betterment, one; 
negative, two. 

(8) Yes, once. Cure. 

(9) Four. Negative in all ; no complications. 

( 10 ) About half a dozen cures ; excellent pallia- 
tive at times. 

(11) No answer. 

(12) Six times; good results in all. Inverted 
U with base in perineum. 

(13) Perineal, as a rule. After-treatment 
simpler and safer. 

( 14 ) Severe bleeding, tearing of rectum ; great 



PROSTATIC HYPERTROPHY. 147 

difficulty in removing prostate; friable and adher- 
ent capsule, anuria and uraemia. 

(A) Palliative, except when obstructive. Symp- 
toms are progressive. Continuous catheterization 
for acute vesical infection; overstretching for ob- 
struction associated with small prostate; galvano- 
cautery for the same condition should overstretch- 
ing fail. X-ray and cystoscope for stone in all 
cases characterized by great pain and obstinate 
cystitis. Prostatectomy by perineal route as a 
rule. 



148 PROSTATIC HYPERTROPHY. 

DENNIS J. HAYES. M. D.. 

Of Milwaukee, Wis. 

(1) I cannot answer. 

(2) I do not know. 

(3) I do not know. 

(4) I have never used it for that purpose. 

(5) I have found it in both temperate and in- 
temperate. Eegarding constipation I can not say. 

(6) Early withdrawal of residual urine under 
strict antiseptic precautions. If the amount is 
large gradual withdrawal extending over a week's 
time with patient in bed. Internally urinary anti- 
septics. Urotropine first place. If cystitis is 
present irrigation of bladder daily, internally, rem- 
edies to overcome the existing constipation. 

(7) Never have made the operation. 

(8) Yes; four cases; complete relief in one 
case ; three were not relieved in the least. The one 
relieved was 64 years old ; very large prostate ; fre- 
quent spells of retention with difficulty in introduc- 
ing instrument of any kind and severe cystitis. 
Castration and supra-pubic cystotomy at same 
time. Supra-pubic channel resume in six weeks. 
Residual urine and cystitis gradually disappeared. 



PROSTATIC HYPERTROPHY. 149 

Prostate atrophied, and now four years and the pa- 
tient is well and works daily. 

(9) No. 

(10) Twenty-five times. All patients were 
more or less benefited. Experienced great difficulty 
in putting suitable drainage tubes. There con- 
tinued more or less cystitis. The operation I think 
is simply palliative and has no power in reducing 
the size of the prostate. 

(11) Never have operated. 

(12) Ten times. Two deaths; one from hypos- 
tatic pneumonia. The other from nephritis and 
uremia. Two cases were followed by urethral fis- 
tula. Six recovered completely with perineal open- 
ing closed and were cured completely by the opera- 
tion. No incontinence able to evacute bladder 
completely and urine clear ; patients able to follow 
their avocations. The two who have fistula are 
quite well, but the fistula will close for a few weeks 
than break open and then close, etc. Eliptical com- 
mencing opposite anus and extending from one 
rami to other. 

(13) Perineal prostatectomy. If the patient is 
in fair condition. I mean if the patient has simply 
a large prostate and severe cystitis, with the upper 
part of urinary tract sound. If there is evidence 



150 PROSTATIC HYPERTROPHY. 

of demoralization of the whole urinary tract, cys- 
titis, ureteritis or pyelonephritis. I would simply 
make supra-pubic drainage under a local anes- 
thetic. I prefer perineal prostatectomy in suitable 
cases, as above stated, because it cures the patients, 
and would perform it in every case where the con- 
dition of the patient and urinary organs would ad- 
mit. 

(14) None in my cases with the exception of 
urethral fistula. I would be pleased to learn the 
technique to prevent urethral fistula following this 
operation. 

A. 

The above will cover my work. 



PROSTATIC HYPERTROPHY. 151 

RAMON GUITERAS, M. D., 

Of New York. 

(1) I have not noticed any particular kind of 
life influencing its development. 

(2) I do not know; most of my cases have been 
thin. 

(3) I do not know. 

(4) In giving us an idea of the outline of the 
base of the gland and of condition of the bladder. 

(5) None. 

(6) Considerably diseased kidneys, for much to 
allowed operation procedure; atonic bladder; cath- 
eterization possible without difficulty or complica- 
tion; over 4 oz. of residual urine; heart feeble; ar- 
teries diseased. 

(7) No. 

( 8 ) Three ; two died, one of whom was maniacal 
for some time before death; the third developed 
melancholia. 

(9) I do not know; usually with no success; 
mortality 6 per cent. 

(10) Never. 

(11) I do not remember. Those that lived had 
good results 1 25 per cent mortality. I rarely per- 
form this operation now. 



152 PROSTATIC HYPERTROPHY. 

(12) I do not remember. The transverse. No 
mortality. Obstinate perineal fistulas in four 
cases. 

(13) Perineal prostatectomy. Vertical perineal 
incision into perineal urethra. Transverse incision 
into the floor of the prostatic urethra and enuclea- 
tion of the gland through this incision. It is simple, 
very little dissection ; not so much opportunity for 
the absorption of septic urine. It affords good 
drainage. 

(14) Rectal fistula in one prostatectomy. Se- 
vere attacks of urinary fever in prostatotomy. 
(Bottini's operation). 

(A) I will soon publish it in a separate article. 
I have done about 50 prostatic operations; 12 per 
cent mortality in prostatectomies: 6% per cent 
mortality in prostatotomy. 



PROSTATIC HYPERTROPHY. 153 

PAOLA DE VECCHI, M. D., 
Of San Francisco, Cal. 

(1) I could not find in my cases any special ref- 
erence to the methods of living. 

(2) All my cases were dark in complexion, 
rather nervous and lean, but I think this condition 
was consequence of the disease. 

(3) All my cases were connected with previous 
inflammation of the urethra and bladder due to 
some infectious diseases and to abuse of coition. 

(4) Cystoscopy has been of a very little, and 
unsatisfactory use, in the diagnosis; first, on ac- 
count of the difficulty of using the instrument on 
account of the enlarged prostate; second, on ac- 
count of the difficulty of keeping the water in the 
bladder clean, long enough for a good inspection. 

(5) The abuse of alcoholics and constipation 
were only an aggravating contribution in two of the 
cases which came under my care. 

(6) In advanced tuberculosis, in nephritis, in 
diseases of the heart which could not stand anes- 
thetics, in diseases of the liver with dropsy. Such 
cases came under my observation, and I thought it 
best not to operate. In fact, two were operated 
with fatal result. In these cases palliative treat- 



154 PROSTATIC HYPERTROPHY. 

ment must be according to the complication, and 
in most cases rest has been beneficial combined with 
the treatment suggested by the special disease. 

(7) I have never practiced it, and I do not 
think it rational. 

(8) Only once and without success. 

(9) The Bottini operation requires a perfect 
knowledge of the technic of the operation, a special 
skill in handling the instrument which is only ac- 
quired by assisting some skillful operator and by 
trying it on the cadaver. I have used the Bottini 
twice with good results and permanent relief, and 
have used the Bottini modified three times; once 
with good and permanent relief, and have used the 
Bottini modified three times; once with good and 
permanent result, and twice with only temporary 
relief. 

These same patients were operated after with 
other methods without relief. 

( 10 ) I have never had an opportunity. 

(11) Only once and with good results, but 
found the operation very bloody and difficult. 

( 12 ) Seven, five with good success ; two are re- 
cent and cannot report the success, although ap- 
parently good. 



PROSTATIC HYPERTROPHY. 155 

I always made the central linear incision, as de- 
scribed by Dr. Goodfellow. 

(13) The operation described by Dr. Goodfel- 
low, because it affords a clear idea of what a sur- 
geon is doing, and with ordinary skill and patience 
the enucleation can be completed even in the most 
difficult cases, and the trauma is certainly not so 
severe as in the other methods. 

(14) The only complication during the opera- 
tion has been the hemorrhage, which was quite for- 
midable in the supra-pubic. And the complication 
which at times gives some trouble in the perineal 
operation of Dr. Goodfellow, is the fistula. How- 
ever, it always closed without trouble in my cases. 

( A ) ( a ) Prostatic hypertrophy is a frequent dis- 
ease, especially in men over fifty years of age. 

( b ) In my cases the causes were always remote 
abuse of coition, protracted urethritis and cystitis. 

(c) Ninety per cent of my cases could be con- 
trolled by palliatives, gradual dilatation of the ure- 
thra, some times combined with rectal massage. 

(d) My choice of operation is the one described 
by Dr. Goodfellow, which can be called prostatic 
digital enucleation through central perineal cut. 



156 PROSTATIC HYPERTROPHY. 

ROSWELL PARK, M. D.. 

Of Buffalo, N. Y. 

(1) No answer. 

(2) No answer. 

(3) No answer. 

(4) Very little. 

(5) In my opinion constipation figures largely, 
alcohol but slightly. 

(6) So long as patient has no troublesome re- 
sidual urine and no decomposition attending, nor 
great difficulty in voiding. 

( 7 ) Three cases. Not followed for final results ; 
temporary improvement. 

(8) Ten or a dozen cases, five with excellent re- 
sults. 

(9) Several times. Hospital cases can't be fol- 
lowed. 

(10) Several times, bad results. Abandoned 
the method in all save cancer cases. 

(11) No answer. 

(12) Eight times, one death. Perineal semi- 
lunar flap. 

( 13 ) Perineal prostatectomy. Ease of perform- 
ance, advantage of perineal drainage. 

( 14 ) No answer. 
(A) No answer. 



PROSTATIC HYPERTROPHY. 157 



CARL BECK, M. D., 

Of New York City. 

( 1 ) Sedentary tends to it mostly. 

(2) The nervous and lean suffer most. 

(3) This is too hard a question for the busy 
practitioner. It is probably a general tendency to 
sclerosis induced by rich and sedentary habits. 

( 4 ) The cystoscope is of much less service than 
thorough palpation. I use Albarran's lately and 
Casper's. 

( 5 ) The two latter items increase the tendency 
considerably. 

(6) If the extent be small and the disturbance 
accordingly so. 

( 7 ) Yes. Twice, and with fairly good results. 

(8) Yes. See Separat-Abdruck aus : "Monats- 
berichte ueber die Gesamteistungen auf dem Geb- 
iete der Krankheiten der Harn-u. Sexual-Appar- 
ate," Bd. II, No. 6 u. 7, 1897. 

(9) I am opposed to the Bottini, although I 
know that in a few instances relief has been ob- 
tained. 

(10) Five times. The result was temporarily 
good. 

(11) Twice. With bad results. 



158 PROSTATIC HYPERTROPHY. 

(12) Nine times. Only one fatal case. 

(13) Perineal prostatectomy. 

(14) Urosepsis after supra-pubic prostatect- 
omy. 

(A) See Separat-Abdruck aus: "Monatsber- 
ichte ueber die Gesamtleistungen auf dem Gebiete 
der Krankheiten der Harn-u. Sexual- Apparate," 
Bd. II, No. 6 u 7, 1897. 



PROSTATIC HYPERTROPHY. 159 

JACOB GKEIGER, M. D.. 

Of St. Joseph, Mo. 

( 1 ) Occupation and pursuits to influence. 

(2) Nervous and lean. 

(3) Gonorrhea and sexual excesses. 

( 4 ) Have not used it. 

( 5 ) Alcoholic and constipation predispose. 

(6) In the very old and feeble and those with 
septic bladder. 

(7) Two cases with much benefit. 

(8) Three cases; two greatly benefited, one no 
result. 

(9) Have not used. 

(10) Four cases; good results. 

(11) Three cases; good result in two cases, 
third case no improvement. 

( 12 ) Have not performed this operation. 

(13) No answer. 

(14) No answer. 
(A) No answer. 



160 PROSTATIC HYPERTROPHY, 

ANDREW C. SMITH, M. D., 

Of Portland, Ore. 

(1) No answer. 

(2) No answer. 

(3) No answer. 

(4) No answer. 

(5) I do not believe that alcohol tends to pros- 
tatic hypertrophy. 

( 6 ) No answer. 

(7) Two. Indifferent results. 

(8) Once. Partial relief. 

(9) No. 

(10) Twice. 

(11) Twice. Good results but more shock and 
much longer convalescence. 

(12) Five times. Best of success, minimum 
amount of shock, rapid convalescence. Median per- 
ineorraphy, as in urethrotomy, has afforded suf- 
ficient room. 

(13) Perineal. Less shock, better drainage, 
more rapid convalescence, simpler, easier, better. 

(14) Some sepsis in supra-pubic cases. 
(A) No answer. 



PROSTATIC HYPERTROPHY. ' 161 

ERNEST G. MARK, M. D., 

Of Kansas City, Mo. 

(1) My cases have been among men who have, 
as a rule, led active lives, though theoretically con- 
sidered I am inclined to the belief that a sedentary 
life would predispose to hypertrophy through favor- 
ing congestion. 

(2) Do not think that these characteristics have 
any special predisposing tendencies. 

(3) My study in this field has led me to the be- 
lief that prostatic hypertrophy is the result of a 
chronic inflammatory process producing new con- 
nective tissue formation. The etiologic agent is 
usually the gonococcus. 

(4) Cystoscopy has been of great benefit in de- 
termining the character of the hypertrophy, i. e., as 
to the direction and extent of the encroachment. I 
use Bransford Lewis' instrument preferably. 

(5) Constipation may play a part in producing 
congestion. 

( 6 ) I advise palliation only in those cases where 
a radical procedure is not to be considered on ac- 
count of the physical condition of the patient. Pal- 
liation consists of regular aseptic catheterization 
and irrigation. 



162 PROSTATIC HYPERTROPHY. 

(7) Have not done this procedure. 

( 8 ) Have not done this procedure. 

(9) Have done Bottini' s operation once, in De- 
cember, 1902, in a patient seventy-seven years of 
age. Perfect success. It is too early in this case 
to make any statement as to permanency. I am 
inclined to the belief that the Bottini does not af- 
ford a permanent cure except in exceptional cases. 

(10) Have never practiced supra-pubic drain- 
age for this condition, nor do I consider it a pro- 
cedure to be thought of except as an emergency pro- 
cedure. 

(11) Have never done this procedure, having 
never found a case suitable for it. 

(12) Have done two perineal prostatectomies 
with perfect results. The curvilinear incision be- 
tween the tuberosities of the ischium affords ample 
room. 

( 13 ) Have no choice and believe that the opera- 
tion should be made to apply to the individual case, 
the character of the enlargement being taken into 
consideration. 

(14) Have had no unexpected complications. 
(A) Have done two perineal enucleations and 

one Bottini, all three cases being successful. 



PROSTATIC HYPERTROPHY. 163 

WILLIAM JONES. M. D., 

Of Portland, Ore. 

(1) I have met with it most frequently among 
farmers. 

(2) Have noted no difference in these differ- 
ent classes. 

(3) Any conditions favoring chronic conges- 
tion. 

(4) Have not used it. 

(5) Not influenced by habit, according to my 
observation. 

(6) Cases where there is but little residual 
urine and only moderate cystitis. Then irrigations, 
and urinary antiseptics internally. In very old 
and infirm, regular catheterization and irrigation 
in presence of considerable residual urine and 
where operation would not be well borne. 

(7) No. 

(8) Once. Disappearance of hypertrophy, but 
amount of residual urine (oz. x) not diminished. 

(9) No. 

(10) Only a few times. Not more than six. 
Results unsatisfactory. 

(11) Once. After supra-pubic drainage for 
several weeks in presence of suppurative orchitis, 



164 PROSTATIC HYPERTROPHY. 

induced by violent and unsuccessful efforts at cath- 
eterism. Death on second day. 

(12) Four times. All lived. All were made 
comfortable by the operation and still are so. Trans- 
verse semi-elliptical. 

(13) Perineal. It is done under direct vision. 
Bleeding vessels can be secured, shock is less, drain- 
age is more perfect and the after-treatment is sim- 
pler, neater and shorter. It seems to me a more 
accurate and surgical procedure, less dangerous 
primarily and there is less danger from sepsis. 

(14) No answer. 

(A) Five cases. One supra-pubic, septic at 
time of operation. Old man, died on second day. 

Four perineal. One with severe cystitis. All re- 
covered and are leading comfortable lives. 



PROSTATIC HYPERTROPHY. 165 

GEORGE M. PHILLIPS, M. D., 

Of St. Louis, Mo. 

(1) I have not been able to decide that occupa- 
tion influences the development of strict prostatic 
hypertrophy. 

(2) The greater number of my cases have been 
lean and of a nervous temperament. 

(3) Undecided. 

(4) Rarely have I been able to use the cysto- 
scope in this situation with much satisfaction. 
Usually hemorrhage attends the application of the 
instrument and renders the parts unfit for inspec- 
tion. I think Dr. Bransford Lewis' the best in- 
strument. 

( 5 ) The twenty-eight cases that I have followed 
and preserved my records of, eleven only were ad- 
dicted to the use of alcohol in any form. 

( 6 ) ( a ) Extreme age and the debilitated. 

(b) Hygiene in all that the term implies, rest 
to the bladder and urinary tract as far as it is pos- 
sible to obtain, all done with a view of developing 
a favorable condition for operation. 

(7) Yes; in twenty to twenty-five instances; a 
small percentage were really benefited. All for a 
time admitted improvement. All in all am of the 



166 PROSTATIC HYPERTROPHY. 

opinion that but little real good was accomplished. 

(8) Yes, nine times. I believed at the time 
the conditions were improved in all. Subsequently 
it developed that in only three instances were the 
patients satisfied. It became necessary to operate 
on four, doing a perineal prostatectomy. 

( 9 ) Yes, twenty times. I have been able to fol- 
low only eight cases longer than a month or two; 
four of these were greatly benefited, four im- 
proved. I have had many complications following 
this operation. Excessive and prolonged hem- 
orrhage, orchitis and epididymitis in several in- 
stances. 

( 10 ) Five times. It is a troublesome means of 
palliation, to be resorted to only when other means 
fail. 

(11) Ten times. The cases that I have been 
able to observe as a rule have fared well. Twice 
have I had infiltration of urine and abscess of the 
abdominal wall to contend with; both cases re- 
covered. 

(12) Sixteen times; the median incision nine 
times, the curved incision from tuberosity to tuber- 
osity three times and the left lateral four times 
The transverse. 

(13) Perineal prostatectomy. 



PROSTATIC HYPERTROPHY. 



167 



(14) (a) Suppression of urine. (5) Ab- 
scesses. Incontinence of urine and feces. 

(A) Not having as correct record of my work 
as some, in a general way I will say that all work 
done here aside from the removal of the organ is 
uncertain. It is my custom to-day to advise a pros- 
tatectomy, either supra-pubic, perineal, or the two, 
in all cases where surgery is positively indicated 
and the condition of the patient will permit. 



LIST OF ILLUSTRATIONS. 



PAGE. 

(1) Anatomy of Prostate 16 

(2) Anatomy of Prostate 16 

(3) Hypertrophy of the Prostate 21 

(4) Prostatic Hypertrophy from (Clay Model) 25 

(5) Median Perineal Incision 31 

(6) Zukerkandl's Incision 31 

(7) Kocher's Incision 35 

(8) Senn's Incision 35 

(9) Prostate and Membranous Portion of Urethra. .39 
(10) Operation Completed 39 



• 



INDEX. 



PAGE. 

Albarran Cystoscope 104, 110, 157 

Anatomy of Prostate 15 

Andrews, Edmund 112 

Beck, Carl 157 

Bernays, A. C 66 

Bottini Operation 

28, 30, 43, 52, 59, 69, 76, 84, 88, 92, 95, 98, 102, 
105, 106, 108, 111, 113, 114, 118, 119, 123, 126, 127, 
129, 132, 136, 140, 142, 144, 146, 149, 151, 154, 156, 
157, 159, 160, 162, 163, 166. 

Bryson's Operation 118 

Casper's Cystoscope 73, 101, 110, 157 

Castration for Prostatic Hypertrophy 

28, 30, 43, 52, 57, 69, 75, 84, 88, 91, 95, 98, 102, 
104, 106, 108, 111, 112, 114, 118, 119, 123, 126, 127, 
129, 132, 136, 140, 142, 144, 146, 148, 151, 154, 156, 
157, 159, 160, 162, 163, 166. 

Chassaignac, Charles 83 

Christian, Hilary M 104 

Cystoscope in Diagnosis 27 

Dandridge, N. P 127 

DeVecchi, Paola 153 

Dowd, J. Henry 138 



172 INDEX. 

PAGE. 

Eastman, J. Rilus 101 

Etiology of Prostatic Hypertrophy 

27, 30, 50, 53, 64, 70, 78, 85, 89, 92, 95, 99, 103, 
105, 106, 108, 111, 113, 114, 118, 121, 123, 126, 127, 
129, 132, 137, 140, 143, 145, 146, 149, 152, 154, 156, 
158, 159, 160, 162, 164, 166. 

Examining for Prostatic Hypertrophy 23 

Ferguson, Alexander H 94 

Ferguson's Operation 70 

Fuller, Eugene 97 

Geiger, Jacob 159 

Glenn, W. Frank. . 136 

Goodfellow's Operation 79-155 

Greene, Robert B 117 

Guiteras, Ramon 151 

Hayes, D. J 148 

Halstead, A. E 122 

Horwitz, Orville 55 

Jones, William 163 

Kochner's Incision 35 

Kollmann's Cystoscope 110 

Lewis, Bransf ord 43 

Lewis' Cystoscope 43, 55, 136, 161, 165 

Lilienthal, Howard 91 

Mayo, Charles H 142 



INDEX. 173 

PAGE. 

MacDonald, George C 131 

MacGowan, Granville 71 

McGuire, Stuart 125 

Mark, Ernest G 161 

Martin, Edward 146 

Morris, Robert T 106 

Morton, Henry H 87 

Mnrphy, John B 52 

Nitze Cystoscope 30, 73, 83, 87, 104, 110, 146 

Otis, William K 144 

Ochsner, Albert J 128 

Park, Roswell 156 

Phillips, George M 165 

Prostatectomy, Perineal 

28, 30, 50, 53, 64, 70, 78, 85, 89, 92, 95, 99, 103, 
105, 106, 108, 111, 113, 114, 118, 121, 123, 126, 127, 
129, 132, 137, 140, 143, 145, 146, 149, 152, 154, 156, 
158, 159, 160, 162, 164, 166. 

Prostate, Physiology of 19 

Prostatic Hypertrophy, Etiology of 

27, 30, 43, 52, 55, 66, 71, 83, 87, 91, 94, 97, 101, 
104, 106, 108, 110, 112, 114, 117, 119, 122, 125, 127, 
128, 131, 136, 138, 142, 144, 146, 148, 151, 153, 156, 
157, 159, 160, 161, 163, 165. 



174 INDEX. 

PAGE. 

Cystoscope in Diagnosis of 

27, 30, 43, 52, 55, 68, 71, 83, 87, 91, 94, 97, 101, 

104, 106, 108, 110, 112, 114, 117, 119, 122, 125, 127, 

128, 131, 136, 138, 142, 144, 146, 148, 151, 153, 156, 

157, 159, 160, 161, 163, 165. 

Operation of Choice for 

28, 30, 50, 53, 64, 70, 79, 85, 89, 92, 95, 99, 103, 

105, 107, 108, 111, 113, 114, 118, 121, 123, 126, 127, 

129, 132, 137, 141, 143, 145, 146, 149, 152, 155, 156, 

158, 159, 160, 162, 164, 166. 

Palliative Treatment of 

27, 30, 43, 52, 56, 68, 73, 83, 87, 91, 94, 98, 102, 
104, 106, 108, 110, 112, 114, 118, 119, 122, 126, 127, 
128, 132, 136, 139, 142, 144, 146, 148, 151, 153, 156, 
157, 159, 160, 161, 163, 165. 

Pathology of 20 

To What Extent Habit is Responsible for 

27, 30, 43, 52, 55, 68, 73, 83, 87, 91, 94, 98, 101, 
104, 106, 108, 110, 112, 114, 118, 119, 122, 125, 127, 
128, 132, 136, 138, 142, 144, 146, 148, 151, 153, 156, 
157, 159, 160, 161, 163, 165. 

To What Extent Occupation is Responsible for . . 
27, 30, 43, 52, 55, 66, 71, 83, 87, 91, 94, 97, 101, 
104, 106, 108, 110, 112, 114, 117, 119, 122, 125, 127, 
128, 131, 136, 138, 142, 144, 146, 148, 151, 153, 156, 
157, 159, 160, 161, 163, 165. 



INDEX 175 

PAGE. 

Unexpected Complications During Operation for 
29, 30, 50, 53, 64, 70, 80, 85, 90, 92, 95, 99, 103, 
105, 107, 108, 111, 113, 114, 118, 121, 124, 126, 127, 
129, 133, 137, 141, 143, 145, 146, 150, 152, 155, 156, 
158, 159, 160, 162, 164, 167. 

Which Suffer Oftenest, Phlegmatic or Nervous, 
Lean or Obese! 

27, 30, 43, 52, 55, 66, 71, 83, 87, 91, 94, 97, 101, 

104, 106, 108, 110, 112, 114, 117, 119, 122, 125, 127, 
128, 131, 136, 138, 142, 144, 146, 148, 151, 153, 156, 
157, 159, 160, 161, 163, 165. 

Resume of Prostatic Work 30, 50, 53, 69, 80 

Ricketts, B. Merrill 108 

Rochester Cystoscope 106 

Senn, Nicholas 30 

Smith, Andrew C 160 

Spencer, Walter G 114 

Suprapubic Drainage, Estimate of Results 

28, 30, 50, 52, 63, 69, 78, 85, 89, 92, 95, 99, 102, 
.105, 106, 108, 111, 113, 114, 118, 120, 123, 126, 127, 

128, 132, 136, 140, 142, 145, 146, 149, 151, 154, 156, 
157, 159, 160, 162, 163, 166. 

Suprapubic Prostatectomy, Results Obtained 

28, 30, 50, 53, 64, 70, 78, 85, 89, 92, 95, 99, 102, 

105, 106, 108, 111, 113, 114, 118, 120, 123, 126, 127, 

129, 132, 136, 140, 143, 145, 146, 149, 151, 154, 156, 
157, 159, 160, 162, 163, 166. 



176 INDEX. 

PAGE. 

Urethroscope, Swinburne's 55 

Valentine, Ferd 110 

Vasa Deferentia, Ligation of 

28, 30, 43, 52, 56, 68, 75, 84, 88, 91, 95, 98, 102, 
104, 106, 108, 111, 112, 114, 118, 119, 122, 126, 127, 
128, 132, 136, 139, 142, 144, 146, 148, 151, 154, 156, 
157, 159, 160, 162, 163, 165. 

Wappler's Cystoscope 144 

Wishard, Willam N 119 

Wyeth, John A 27 

Young's Cystoscope 144 



